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Glass. 
Book. 



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Conservation of 

School Children 



Being the Papers and Discussions of a Conference 
at Lehigh University, April 3 and 4, 1912 

Under the Auspices of the American Academy of Medicine 

together with 

Several papers (not presented to the Conference) prepared 
for this Volume 

Reprinted from the Bulletin of the American Academy of Medicine 



EASTON, PA. 

PRINTED FOR THE AMERICAN ACADEMY OF MEDICINE. 

1912. 






r 



FOREWORD. 

The Conference on the Conservation of School Children under 
the auspices of the American Academy of Medicine was held 
at Lehigh University, South Bethlehem, on April 3 and 4, 19 12. 
The sessions of the Conference were held in Drown Memorial 
Hall, which was kindly placed at the disposal of the Conference 
by the University authorities. 

At the first session (Wednesday, April 3rd, 2 p.m.) the Presi- 
dent of the Academy, Dr. Alexander R. Craig, of Chicago, in 
calling the meeting to order, said : 

This Conference is called to discuss a subject that interests the public. 
We are grateful for your attendance and we want you to feel that this is not 
a meeting of the American Academy of Medicine but a conference of all 
interested in the subject. The discussions are open to any who have thoughts 
to add to those presented in the papers read, questions to ask or comments 
to make on the subject presented; you are welcome to the floor of the con- 
ference whenever you will contribute to its discussions. 

The Secretary of the Academy then presented the program for 
the Conference and explained the registration system, making 
a distinction between the members of the Conference and visitors, 
a registration fee of two dollars being charged to the former 
which entitled them to a badge and a copy of the transactions 
of the Conference. He also called attention to the invitation 
of the President of Lehigh University for the Conference to make 
use of the University Commons, thus enabling the social oppor- 
tunities of the meeting to be increased. 

The President introduced Henry S. Drinker, LL.D., President 
of Lehigh University, who said: 

Mr. President, Ladies and Gentlemen of the Academy, our Guests: 
The University is highly honored to be allowed to be the host of this dis- 
tinguished body and you are very welcome. We hope we shall be able to 
make you comfortable. It will certainly be our object and pleasure to do 
whatever we can to minister to your wants and show you how welcome you 
are. 



Some of you have come from a distance — one gentleman from Minnesota — 
and may wish to know something about this institution. Lehigh is pe- 
culiarly a Pennsylvania institution. It was founded by a Pennsylvanian 
who did much to develop our transportation, our industrial and our mining 
interests — Asa Packer. It was founded by him to make some return to the 
State of Pennsylvania for what Pennsylvania gave him. He did a good 
work, in starting this University, for the Lehigh Valley, for our state, and 
■for the country at large. The conditions have been markedly changed since 
its founding. As you go over to the town you will probably notice a small 
brick building facing on the street that runs east and west to the north side 
of the campus. That was the original Lehigh University. At the time it 
was built it was a Moravian Church. Judge Packer bought it and pro- 
vided another site for the church. Lehigh has naturally developed since 
those days, but what is significant to us who have graduated from this in- 
stitution is that Judge Packer in 1866 is said to have made the largest dona- 
tion to public education up to that time. He gave more than two million 
during his life and at his death, and no doubt set the pace for the many gifts 
that have come since this to the cause of education in America. So he not 
only founded this institution but he pioneered those who followed him in the 
generous promotion of education in our country. 

Lehigh has made her main reputation on the technical side. Naturally 
she should, being located here at a railroad center and near the anthracite 
mining region — and at the time she was founded — in the middle of iron and 
zinc interests, some of which have since died down. A location peculiarly 
favorable for the development of technical work, but I ask you gentlemen 
of the medical profession to remember that Lehigh too has had at heart what 
you and I know, that the foundation of a thorough technical training should 
be a broad culture. 

If you have time to go over our grounds I beg you to give us the benefit 
of your inspection of our buildings and courses. You are here in vacation 
time, so you will have a free foot. You should understand that this build- 
ing is the Academy's during the time of your stay. The ladies will find 
comfortable resting rooms in the Y. M. C. A. quarters. Drown Hall is our 
Students' Club House, started by our Alumni with the help of friends of the 
institution, so that our students might have their own place. It is run and 
managed by the student body under the system at Lehigh of student manage- 
ment of everything possible to turn over to them. We have a student or- 
ganization managing the honor system in the University and which is also 
charged with all matters affecting the good name and fame of the institu- 
tion and I think they bear their responsibility well. 

To-night I belie ve. the University is peculiarly charged with your care, 
and it struck us that (as is often done in meetings of this kind) it would be 
well to have one of our meetings devoted to social intercourse. Therefore 
after Dr. Lovejoy's address this evening we shall have a social gathering 



and try to show you how very, very welcome you are, and how delighted 
Lehigh is to have you here. 

Dr. Craig, as President of the American Academy of Medicine, 
responded to the address of welcome as follows : 

It falls to my lot to make response to this very courteous and very warm 
welcome. Before doing this, however, I want to assure you again that the 
discussions of this Conference are not limited to members of the Academy of 
Medicine. This is a conference of those interested in the conservation of 
school children. While held under the auspices of the Academy, the mem- 
bers of that organization will have no privileges that are not accorded to all 
in attendance. The American Academy of Medicine realizes that these 
subjects are not strictly medical, they belong to the people. The physician 
is interested in them because he meets them in his work as he goes from house 
to house, as he visits this and that hospital, or other institution; as patients 
from their physical sufferings come to his door seeking relief. Constantly 
he feels the need of a new sociologic adjustment. He has tried to better 
conditions but he has found a wall opposing the efforts he has made to benefit 
society. His active interest in public health movements has been misunder- 
stood; frequently when he has asked for legislation that a sociologic evil 
might be corrected, it has seemed that his interest has roused adverse senti- 
ment and has caused the people to say: "This is a doctor's 'job;' we do not 
understand his interest, and will not stand for the restriction of personal 
liberty asked." Now we come to you trying to show you that the solution 
of these problems is not a doctor's "job," nor is it the doctor's "job;" but 
it is the duty, the high office of the citizens of the state. The citizen must 
defend the commonwealth by conserving not only its physical forces, but the 
forces of humanity in the community. With this as our purpose, we assemble, 
accepting the hospitality of a great university, to discuss themes of great 
interest to physicians because they are of value to the people. We thank 
Dr. Drinker and Lehigh University for the kind welcome given us and we are 
sure we are to have a delightful and profitable meeting. 

The reading of papers was then entered upon and the follow- 
ing program carried out: 

"Remediable Conditions in the Feeble-Minded and Backward" 
was presented by Walter Stewart Cornell, B.S., M.D., Phila- 
delphia, Lecturer on Child Hygiene, University of Pennsylvania. 
The discussion upon this paper was opened by Maximilian P. E. 
Groszmann, Pd.D., Plainfield, N. J., Educational Director of 
the National Association for the Study and Education of Ex- 
ceptional Children, and continued by Drs. Tuckerman and Carey, 
Dr. Cornell closing. 



The second paper was presented by Joseph S. Neff, M.D., 
Philadelphia, Director of Public Health and Charities, on "How 
to Secure State Appropriations for the Proper Care of the Feeble- 
Minded." This paper was discussed by Drs. Groszmann and 
Neff. 

"How Far Shall the Public School System Care for the Feeble- 
Minded?" was presented by Andrew W. Edson, New York, As- 
sociate City Superintendent of Schools of the City of New York; 
J. H. Van Sickle, Springfield, Mass., Superintendent of Schools; 
and E. Bosworth McCready, M.D., Pittsburgh, Medical Director, 
Hospital School for Backward Children. William G. Schauffler, 
A.B., M.D., Lakewood, N. J., President of the State Board of 
Education of New Jersey, opened the discussion on these papers; 
it was continued by Miss Johnson, of New York City, Dr. Button, 
of Rochester, N. Y., Dr. Groszmann, Dr. Zatae L. Straw, of 
Manchester, N. H., Dr. Bracken, of Minneapolis, Dr. Tuckerman, 
and closed by Mr. Edson. It was further discussed by Dr. 
Cornell and Dr. McCready closed. 

After an enjoyable supper at the Commons, the Conference 
met at seven-thirty, under the presidency of Dr. Henry S. Drinker, 
President of Lehigh University. Dr. Henry H. Goddard, of the 
Vineland Training School, was unable to be present and his paper 
was read by title. The discussion upon it from the printed 
abstract in the program was opened by Dr. Alexander Marcy 
Jr., Riverton, N. J., and continued by Drs. Carey and Cornell. 

The address of the evening was by Mr. Owen R. Lovejoy, 
of New York, the Secretary of the National Child Labor Com- 
mittee, on "Child Labor vs. the Conservation of School Children." 

The address was discussed by Mr. Nusbaum, Drs. Groszmann, 
Bracken, Cornell, Drinker and Baker, and Mr. Lovejoy. 

At the conclusion of the discussion the Conference adjourned 
and was tendered a reception by Lehigh University, which was 
very much enjoyed. 

The Conference reassembled on Thursday morning shortly after 
nine o'clock, with the Rev. Paul deSchweinitz, D.D., of Bethle- 
hem, presiding. The general subject for the morning session 



was "Teaching Hygiene" with several sub-topics. Under the 
sub-topic, "What Should be Taught?" Seneca Egbert, A.M., 
M.D., Philadelphia, Dean of the Medico Chirurgical College, 
spoke on "The Physician's Point of View;" while Percy Hughes, 
A.M., Ph.D., South Bethlehem, Professor of Philosophy and 
Education, Lehigh University, presented "The Teacher's Point 
of View." The discussion on these two papers was opened by 
F. D. Raub, Superintendent of Schools, Allentown, and continued 
by Drs. Groszmann, Putnam, Tuckerman and Weaver. 

Under "How Should Hygiene be Taught?" W. S. Steele, A.M., 
LL.B., Harrisburg, Principal of the Harrisburg High School 
spoke of the "Methods in Vogue," and Louis Nusbaum, Phila- 
delphia, District Superintendent Public Schools, read "Improve- 
ments Suggested." The discussion of these topics was opened 
by James S. Grim, Ph.D., Kutztown State Normal School, and 
continued by Miss Sara Phillips Thomas, Philadelphia, State 
Superintendent of Scientific Instruction, W. C. T. U. 

Thomas D. Wood, M.D., Teachers College, Columbia University, 
and Helen C. Putnam, A.B., M.D., Providence, R. I., spoke 
on "Teaching Hygiene for Better Parentage." 

"Indirect Methods of Teaching Hygiene" was presented 
by C. E. Ehinger, M.D., West Chester, Pa., Physical Director, 
State Normal School. 

The Conference enjoyed another pleasant social hour in the 
Commons and met at two p.m. in the final session, with Mr. N. 
M. Emery, Vice-President of Lehigh University, in the chair. 
The general topic for the afternoon was "Medical Inspection." 
J. F. Edwards, M.D., Pittsburgh, Superintendent of Bureau of 
Infectious Diseases, spoke "From the Standpoint of the Board of 
Health ;" Thomas A. Storey, M.D., Ph.D., New York, Professor and 
Director of Physical Instruction and Hygiene, College of the City 
of New York, "From the Standpoint of the Educator." 

William Charles White, M.D., Pittsburgh, Professor of Medicine, 
University of Pittsburgh and Medical Director of Tuberculosis 
League, presented "Measures for Prevention of Respiratory 
Infection in the Schools." Watson L. Savage, A.B., M.D., 
Pittsburgh, President New York Normal School of Physical 



Education and Student Health Supervisor Carnegie Technical 
Schools, opened the discussion, which was continued by Mrs. 
John L. Stewart, Mr. Emery, Miss Thomas, Drs. Kuntz, Burns, 
Button, Mrs. Stilwell, Drs. Egbert, Richards, Storey, Martin, 
Putnam, Cornell, Bracken, Jackson and closed by Dr. Storey. 

Ira S. Wile, M.S., M.D., New York, read "The Relative Physical 
Advantages of School Lunches in Elementary and Secondary 
Schools," which was discussed by Drs. Button and Baker. 

At the conclusion of the discussion, Dr. J. E. Tuckerman, 
of Cleveland, presented the following resolution, which was 
moved and adopted by a rising vote, the question being put 
by the Secretary, after which the Conference adjourned : 

The American Academy of Medicine and the members of the Conference 
desire to express their sincere appreciation of the cordial hospitality and 
excellent arrangements provided by Lehigh University; to extend their 
hearty thanks to all whose endeavors and manifest interest have made the 
Conference a marked success — especially to those who have taken part in the 
program, to the students who have contributed so much to the physical 
comfort of all who have been privileged to enjoy the Commons; and also to 
the representatives of the press for their courtesies. 

MEMBERS REGISTERED AT THE CONFERENCE. 

Illinois. Plainfield. 

Chicago. Groszmann, M. P. E. 

Craig, Alexander R. Riverton. 

Minnesota. Marcy, Alexander, Jr., President of 

St. Paul. the New Jersey Society for the 

Bracken, H. M., Sec. State Board of Prevention of the Social Diseases. 

Health. new york. 

NEW Hampshire. New York City. 

Manchester. Edson, Andrew, Assoc. City Supt. of 

Straw, Zatae L. Schools. 

new jersey. Johnson, Eleanor H., Member of 

Bayonne. School Board. 

Corwin, H. M., Medical Inspector. Lovejoy, Owen R., Sec 'y Child Labor 

Jersey City. Committee. 

Brickerhoff, H. H., Medical Inspec- Storey, Thomas A., Prof, of Hy- 

tor. giene, College of City of New York. 

Hulsizer, P. S., Principal of School. Wile, Ira S. 

Lakewood. Wood, Thomas D., Prof, of Hy- 

Schaumer, W. G., Pres. State Board giene, Teachers College, Columbia 

of Education. Univ. 



Rochester. 
Button, L- L., Medical Examiner. 

White Plains. 
Sell, E. H. M. 

OHIO. 

Akron. 
Bradley, Isabel A. 

Cleveland. 
Tuckerman, J. E. 

PENNSYLVANIA. 

Allentown. 
Butz, J. Treichler. 
McGettigan, E. J. 
Raub, F. D., Supt. of Schools. 
Smith, C. J. 

Weaber, Thomas H., Medical In- 
spector. 

Bethlehem. 
Boyle, F. T. 
Clewell, Rev. J. H. 
Farrar, H. B. 
Roest, Edward C. 
Schweinitz, Rev. Paul de 

Coaldale. 
Beale, J. E. 

Easton. 
Fretz, John E. 
Green, Edgar Moore 
Heberling, J. S., Supt. of Carter 

Junior Republic. 
Mclntire, Charles 

Emaus. 
Backenstoe, M. J. 

Harrisburg. 
Schaeffer, N. C, State Supt. of 

Education. 
Steele, W. S., Principal High School. 

Haverford. 
Winton, Mary 

Hecktown. 
Beck, Richard H. 

Johnstown. 
Wray, Gertrude W. 



Kutztown. 
Grim, James S., Professor of 
Biology, Normal School. 
Lansford. 
Kuntz, Elmer E., Boro Supt. 
Mauch Chunk. 

Bevan, J. J., County Supt. of 

Schools. 
Jackson, H. R., Principal of Schools. 

Norristown. 
Weaver, Joseph K. 

Philadelphia. 
Alexander, Lydie C. 
Cornell, Walter S., Director of 

Medical Inspection in the Public 

Schools. 
Egbert, Seneca, Dean Medico-Chirur- 

gical College. 
Moxey, A. F. 
Neff, J. S., Director of Public Health 

and Charities. 
Nusbaum, Louis, Dist. Supt. of 

Schools. 
Richards, Florence H., Medical 

Director of William Penn High 

School. 
Spiegle, Grace E., Professor of 

Hygiene, Philadelphia Normal 

School. 
Stilwell, Mrs. Clara P. H. 
Thomas, Miss Sara P., Supt. of 

Scientific Instruction, Pa. W. C. 

T. U. 

Phoenixville. 
Laramy, Robert E., Supt. of Schools. 

Pittsburgh. 
Burns, H. B., Medical Inspector. 
Chambers, Will Grant, Dean School 

of Education, Univ. of Pitts- 
burgh. 
Edwards, J. F., Supt. of Bureau of 

Infectious Diseases. 



IO 



Martin, Elizabeth L., Professor of 
Hygiene, Carnegie Technical 
Schools. 

McCready, E. Bosworth, Medical 
Director Hospital School for Back- 
ward Children. 

Savage, W. L. 

White, William C, Medical Director 
Tuberculosis League. 

Richlandtown. 

Brown, Walter H. 

South Bethlehem. 

Dinan, Elizabeth A., Probation 
Officer. 

Drinker, Henry S., President, Lehigh 
University. 

Emery, N. M., Vice-Pres. Lehigh 
University. 

Estes, William L. 

Hughes, Percy, Prof. Philosophy and 
Education, Lehigh University. 



Miller, Mrs. B. L. 
Richards, Mrs. J. W. 
Sassaman, Clara. 

South Langhorne. 
Randall, Helen M., Supt. Foulke and 
Long Institute. 

Spring City. 
Carey, H. M., Supt. Eastern Penna. 
State Institution for the Feeble- 
Minded and Epileptic. 
Weatherly. 
Zichman, W. L., Supervising 
Principal. 

West Chester. 
Baker, Jane K. 

Ehinger, C. E-, Physical Director 
State Normal School. 

RHODE ISLAND. 

Providence. 
Putnam, Helen C. 



I. 

REMEDIABLE CONDITIONS IN THE FEEBLE-MINDED 
AND BACKWARD. 1 

By Walter Stewart Cornell, M.D., Philadelphia, Director of Medical Inspection in 

the Public Schools. 

This subject derives its practical importance from the recent increase in 
our knowledge concerning the hereditary transmission of feeble-mindedness, 
the association of feeble-mindedness in many cases with pauperism, vice, 
illegitimacy and crime and the present endeavor by those interested in social 
work to induce those in authority to provide more and better facilities, for 
the feeble-minded in institutions, and for the dull in special classes in the 
public school system. 

The problem of remediable conditions in the case of dull chil- 
dren is theoretically simple, because here only the common and 
familiar defects of malnutrition, defective vision and defective 
hearing, and the social defect of poor home conditions need be 
considered. Marked improvemeat of the feeble-minded however 
is a difficult unsolved problem, and the hope of improvement 
of border-line cases (a numerous group) is almost as remote owing 
to the existence of feeble-mindedness in a large proportion of 
these cases and to uncertainty of diagnosis in all. 

In this short paper, the feeble-minded and the dull will be 
discussed separately, its purpose being to emphasize the basic 
differences between the two groups with consequent basic dif- 
ferences in treatment and in expectation of improvement. 

FIRST, CAN FEEBLE-MINDEDNESS BE CURED? 

At the present time no means are known whereby a feeble- 
minded person may be made into a normal individual. The only 
exception is found in that special type of the feeble-minded, 
known as cretins, who are cured or marvelously improved by the 
administration of thyroid extract. The cretin type, however, 
constitutes but a fraction of one per cent, of all the feeble-minded. 

The hope of complete cure is based on several theories which 
are at least worth considering. The slender chance afforded by 

1 Read at the Conference on the Conservation of School Children, Lehigh University, 
April 3, 1911. 



12 

them, however, certainly does not extend to those feeble-minded 
persons (about one-fifth of the whole number) who are the result 
of brain injury or brain disease affecting normal individuals in 
early life. Also hope of cure in all the feeble-minded, no matter 
what medical discoveries may be made, must diminish with in- 
crease of age, since there is a physiological law that any part of 
the body retarded too long in its development is incapable of 
full normal growth. 

For the sake of clearness, it may be well to set down categor- 
ically the different theories of the cause of feeble-mindedness 
and then consider these causes and the appropriate remedies 
serially. 

i. Exhaustion of nervous vitality. 

2. Exhaustion of general vitality. 

3. Abnormality in the cellular elements throughout the body, 
arising from some abnormality in one or both parental germ 
cells. 

4. Under-f unction of one or more of the glands of internal secre- 
tion. 

5. Origin through miscellaneous causes, such as organic brain 
injury, cortical sclerosis, hydrocephalus, intoxication by syphilis 
and alcohol, lack of thyroid and possibly other internal secretions, 
general degeneracy, etc. 

First may be considered the plan of improving the general 
tone of the nervous system with a consequent improvement 
in all its functions. So far as the feeble-minded individual is 
himself concerned, this course of treatment is the one now pur- 
sued in our special training schools, where general hygiene and 
where special mental education based on systematically ex- 
ercising special sense functions, perception, memory, associa- 
tion and reasoning, are employed. Experience has shown that 
the feeble-minded individual himself is never cured of feeble- 
mindedness by the most vigorous training and what hope exists 
is for his offspring possibly several generations remote. Our 
heredity records have shown the transmission of feeble-minded 
stock, but not the generation of feeble-minded stock with the 
subsequent transmission of feeble-minded stock. Neither do 



13 

any of the animal breeding experiments so far conducted show 
such improvement as to furnish an analogy to the reverse process 
of gradual raising of feeble-minded humans to the level of normal 
humans. Another objection to this theory is found in the pos- 
session of numerous and general original physical defects in the 
feeble-minded, pointing to a general inferior structure rather than 
inferiority in the nervous system alone. A final objection, or 
rather discouraging feature is that insanity, often cured by a 
hygienic regime, is now known to have but little relation to feeble- 
mindedness and feeble-mindedness is by far the more transmissible 
and non-improvable of the two. 

Cases of feeble-mindedness apparently produced by parental 
alcoholism or by congenital or inherited syphilis may be brought 
forward for discussion as results of diseases which particularly 
select the nervous system for destruction, but our knowledge 
of the proportion of the feeble-minded arising from these diseases 
is at present so uncertain, and the number of the cases is so un- 
certain and so relatively small, that they are better considered 
as a separate group. 

The second theory of a possible cure of feeble-mindedness is 
based on improvement of general vitality. We know that the 
feeble-minded display not only low mentality, poor co-ordination, 
low nerve-muscular tone, but also inferior musculature and a poor 
resistance to infectious diseases. Their expectation of life is 
short because tuberculosis and pneumonia attack them readily. 
Some reach the age of twenty or thirty years and then appear to 
deteriorate simply from premature decay. The tentatively 
accepted theory of the (special) Mongol type of the feeble-minded 
is that of exhaustion of the germ cells of one or both parents, 
with the production of weakling unfinished offspring. Corrobo- 
rative of this theory is the proven great number and variety of 
physical defects in the feeble-minded, the argument being that 
the cells of the embryo have not possessed the requisite vigor of 
division and arrangement. For instance, over forty per cent, 
possess eyes which would require glasses if their possessors use 
their eyes for reading. Sixteen per cent, show original myopia. 
Valvular disease exists in twelve per cent, of all cases (it is ac- 



14 

knowledged that some of these are not congenital). Malfor- 
mations of the sexual organs, skin appendages and viscera are 
quite common. The average height of feeble-minded males of 
twenty -five years is 62 1 / 2 inches as compared to 66V 2 inches 
height seen in the normal. Can anything be done for this general 
condition of degeneracy and low vitality, conceding this to be 
the correct explanation of the condition? The answer must 
be found in animal breeding experiments, and those so far carried 
out by the American Breeders' Association and by the Carnegie 
Institute have not as yet reached the goal of raising normal from 
degenerate stock. 

Can feeble -mindedness be cured if due to a perversion or ab- 
sence of the molecular elements in a germ cell and subsequently 
in the body cells developed from the germ cells? In other words, 
if the cytoplasm is leaky or one of the chromasomes is too short 
or whatnot, in every embryonic cell, and this in some way in- 
cidentally produces feeble-mindedness, can anything be done? 

It should be noted that this conception of feeble-mindedness 
is entirely different from that in the two ideas previously con- 
sidered. In them the feeble-minded represent simply the lowest 
stratum of mentality in the human race, and all humans may be 
arranged in a series with insensible gradations beginning with 
the most intellectual person and ending with the lowest grade 
idiot. According to this conception, the differences are simply 
quantitative. In the theory now considered feeble-mindedness 
may be looked upon as a sport on the normal human stock (using 
a botanical term) , and therefore constituting a distinct anthropoid 
species with the power of transmitting itself and (assuming two 
feeble-minded parents) without the power of again producing 
normal persons. The difference according to this theory is not 
quantitative, but qualitative. Regeneration of normal stock 
is hopeless if both parents are feeble-minded, and hopeless in a 
predestined number of cases if one parent is feeble-minded. 

The records of animal breeding experiments, and most family 
records of the feeble-minded, do not show with certainty that the 
feeble-minded are a group with definite structural peculiarities 
transmissible over and over again. Two small groups of types 



15 

of the feeble-minded, the microcephalic and the amaurotic idiots 
may be exceptions and exemplify the theory, and among the 
general mass of feeble-minded an occasional remarkable family 
tree is seen which apparently follows some definite natural law 
of reproduction. There is a heredity chart at the Training 
School for Feeble-Minded Children at Vineland, which shows 
the reproduction of feeble-minded persons regularly and con- 
stantly through several generations after a young man of normal 
family had had vicious relations with a feeble-minded woman. The 
identity of this man, now dead, is known; and his descendants 
by his legitimate wife are among the soundest and best citizens 
of New Jersey. Certainly if proof of this indefinite transmission 
of feeble-mindedness is once obtained, the necessity for segrega- 
tion or sterilization of the feeble-minded can be no longer ignored. 
It must be acknowledged, however, that so far our proofs are 
too faulty to provide conclusions except by inductive reasoning. 

Most of the clear cut heredity experiments are carried out in 
plants, rather than animals, and the special characteristics, 
known to be pioduced in humans (albinism, hemophilia) do not 
have any close relation to feeble-mindedness, nor are they found 
in feeble-minded persons more than they are in normal persons. 

Taken together, it would appear more correct to account for 
the tendency of feeble-mindedness to transmit itself by the well 
known tendency of any poor nervous system (whether the case 
be one of neurasthenia, hysteria, insanity, feeble-mindedness, 
Friedreich's ataxia, or a muscular dystrophy) to transmit itself, 
rather than by some more specialized explanation. 

The most hopeful, a priori, of the theories of the causations 
of feeble-mindedness is that one which accounts for the condi- 
tion by a deficiency of certain body secretions whose function 
is to activate the brain and nervous system generally. The 
glands performing this work are certainly the thyroid and the 
anterior portion of the pituitary. The thymus gland apparently 
acts at times as an accessory thyroid and probably has other 
functions as yet unknown. The posterior lobe of the pituitary, 
the suprarenals, the sexual glands, pineal gland and certain glands 
in the head of the pancreas may contribute elements affecting 



i6 

body growth and mental development. Knowing as we do that 
cretinism (one of the two sharp types of feeble-mindedness) 
is due to deficient thyroid secretion, it is plausible that mongolian- 
ism (the other one) is due to lack of some other secretion, say the 
pituitary. Possibly the general mass of the feeble-minded show- 
ing no particular type of characteristics, are due to a general 
shortage in the secretions of these glands. Recently Dupuy, 
a French investigator, has published a paper {Bulletin medical, 
Jan. 3, 19 1 2) claiming remarkable results from mixtures of 
thyroid, pituitary, corpus luteum and orchitic extract, the pro- 
portions of these varying according to the case. Experiments 
conducted at the Training School at Vineland, New Jersey (by 
the writer on Mongols with a mixture of pituitary and thyroid 
extracts, and by Drs. Dana and Berkeley of New York with 
extract of pineal gland), have seemed to produce improvement 
in individual cases and in the case of the pineal feeding, a very 
slight but appreciable improvement in most of the cases treated. 
Knowledge of this phase of nutrition and mental development 
is unfortunately still in the experimental stage. 

Finally must be considered the theory that feeble-mindedness 
is not the expression of one or two or three morbid conditions 
but rather of a considerable number, and that each must be con- 
sidered separately so far as medical treatment is concerned. 
In favor of this view is the long list of causes, some hereditary 
and some originating in the individual, which reasonably account 
for the condition. Parental feeble-mindedness, parental alco- 
holism, parental old age with declining physical vigor, parental 
malnutrition from overwork or tuberculosis, injury to the head 
at the time of birth, infantile cerebral hemorrhage, meningitis, 
hydrocephalus, cortical sclerosis, congenital syphilis, deficiency 
in thyroid secretion, deficiency in pituitary secretion and de- 
ficiency in pineal secretion must all be remembered. It is true 
that a great proportion of the feeble-minded show feeble-minded- 
ness in their ancestors, but the hereditary factor producing the 
feeble-mindedness may possibly be different in different cases, 
so that even here, we may not possess a large solid group of one 
particular sort. If any of the theories already mentioned should 



17 

succeed in giving us a cure for feeble-mindedness, it would there- 
fore be only in one special group, and the other groups would 
still remain a problem. Rather a depressing prospect for the 
research worker, but one that might as well be recoginized at 
the outset. 

Next, may be considered such improvement of the feeble- 
minded AS IS NOW POSSIBLE WITH OUR PRESENT KNOWLEDGE AND 
METHODS. 

One hundred years ago, Seguin changed the view point of the 
world toward the feeble-minded by treating them as children 
with weak minds, rather than as unfortunate objects fit only 
for a hospital or an asylum and not worth considering except 
as specimens of disease. In our own day, Barr of Klwyn pro- 
foundly stirred the social conscience regarding the feeble-minded 
by his book on mental defectives in which the human child was 
emphasized rather than his anatomic defects. Since then 
the education, or better, let us say training, of the feeble-minded, 
has become a recognized special work and this in turn has vivified 
the subject of psychology, and remarkably improved our methods 
of teaching all children. Today the mental improvement of the 
feeble-minded child is accomplished in the school-room, shop 
and garden, rather than in the hospital. With a system born 
of a psychological knowledge, the lowest grade cases are trained 
in the simpler mental processes of sense perception, perception 
of number and form, attention and memory, and the higher 
grade cases are trained to industrial work and to such reasoning 
power as can be produced. To give the feeble-minded brain its 
best opportunity, the eyesight, hearing and nutrition are given 
medical attention when necessary. Recently tests (by the late 
Prof. Binet) measuring the mental development of children from 
three to thirteen years have been devised and those for the ages 
of three to ten years inclusive are quite accurate. By these tests the 
interesting fact is shown that even with the best training methods, 
the rate of improvement is discouragingly low and the feeble- 
minded child drops steadily further and further behind. This 
fact brings home the great price in effort paid by our educational 
and institutional authorities in the tra ; ning of defective children, 



and the wear and tear on the individual teacher as well. It 
also emphasizes the danger of too much school training for a 
feeble-minded child lest his condition be masked and society 
made ultimately to suffer from his pauperism or delinquencies 
while at large in the community. 

We should always bear in mind that physical defects found 
in the feeble-minded are not necessarily causative of mental 
deficiency. Very often, these physical defects are simply as- 
sociated conditions and the expression of a generally defective 
make-up. Some forty per cent, of the feeble-minded possess 
eyes of a character requiring glasses, if the mentality were sufficient 
to warrant the procuring of them. The open mouth seen in these 
children is not always due to originally existing adenoids; the 
jaw is dropped and the child has not sense enough to close it. 
Thereafter the adenoids may appear secondarily, because of the 
constant mouth breathing. 

Third, a few words on the remediable conditions in the 
child who is not feeble-minded, but simply dull. 

The treatment is exactly the same as that already outlined, 
namely, the clearing away of such obstacles as poor nutrition and 
defects in the special senses, individual attention in order that 
difficulties may be overcome, the training of the senses to better 
acuteness through the systematic exercises, the training of the 
motor side through physical and manual training, and the 
assistance of the sub-normal intellect by the use of measures in- 
volving association. 

The Montessori system and other recent systems less talked 
about consist simply of these methods, although in the Montessori 
system a certain emphasis is laid on the education of the sense 
of touch. The truth about all these systems is that special 
measures are necessary in the case of deficient children and super- 
fluous in the case of bright children. For instance, the dull 
child has to be shown how to add by means of balls strung on 
a wire, but the bright child discards this mechanical device after 
a few lessons and thinks quicker than it takes to count the ob- 
jects. The same rule applies to our present method of teaching 
reading in which syllables rather than individual letters are taught. 



19 

Compared to the old method of teaching the letters first, it is 
better for bright children and worse for dull children. 

Physical defects and environment have more relative influence 
in the case of dull children than they do in the case of feeble- 
minded children in whom the deficiency is often inherent and 
obtained in feeble-minded parents. A study by the writer of 
the influence of defective eyesight in school children showed 
that the children of normal vision obtained an average of seventy- 
five points, those of fair vision an average of seventy- three, 
and those with quite poor vision an average of sixty-nine. An 
analysis in the report of the London County Council for 1904 
of the scholarship of 32,000 school boys and 29,000 school girls 
showed that the vision was progressive with the scholarship 
except in the case of the very brightest children whose eyesight 
was not quite as good on the average as the children classed as 
bright but not precociously bright. The relation of adenoids 
to dulness is so well established that it would be superfluous to 
detail the different investigations reported. As to defective 
hearing, it is well to note that most cases of defective hearing 
arise from adenoids and the two may therefore be considered in 
the same group, but a special study given in the report of the 
London County Council for 1907 showed that poor hearing 
existed in almost twice as many of the dull children as it did in 
the bright children. 

Experience has shown that dull children under improved con- 
ditions of health, environment and school training may be greatly 
improved mentally. 

A very interesting study made in one of the special classes of one 
of the Philadelphia Public Schools demonstrated that the average 
child before entering the class had accomplished about thirty- 
five per cent, of a grade per year, and after entering the class 
had succeeded in accomplishing eighty per cent, of the grade 
per year. This improvement does not necessarily imply that 
these children were made into normal children, for the work done 
in the special classes was that ordinarily done by younger children, 
but it certainly has a value from a comparative standpoint 
and points the way to the improvement of great numbers of chil- 
dren now failing to do the ordinary school work. 



20 
DISCUSSION. 

Dr. Maximilian P. E. Groszmann, Plainfield, N. J.: 

I have a great interest in the backward child, and would like to plead 
particularly that the backward child should not be always mentioned in the 
same breath with the feeble-minded child. I think that is a mistake which 
does an injury to the interest of the backward child. As Dr. Cornell has so 
clearly shown, the feeble-minded, as we understand him, is incurable. We 
may remedy some of the difficulties so that the feeble-minded child may not 
be altogether a burden to society. Some may be so educated that they can 
pay by their labor for a part, sometimes for the greater part of their main- 
tenance. 

The backward child, however, is a subject for a great deal of interesting 
and valuable study. He is simply a child with some sort of retarded develop- 
ment, whatever the cause may be. There are of course causes in which the 
physician is interested. Dr. Cornell has mentioned some — defective teeth, 
defective eyesight, or breathing, or hearing. All these are common causes 
of some of the backwardness in children as seen in the schools. For backward 
children are needed special methods of training, and for certain classes even 
special institutions, which give the proper environment. The backward 
child is really the most misunderstood child. He is too often confused with 
the feeble-minded. The statement was made sometime ago that there is 
very little difference between backward and feeble-minded children, that it 
is difficult to make a distinction, and that most of the backward children of 
the public schools are really feeble-minded. I cannot conscientiously sub- 
scribe to this statement. There are, of course, border line cases in which it 
is difficult to differentiate. The difference, however, lies in the fact that the 
backward child is educable, perhaps at a very slow rate, but always opening 
more and more towards the normal; while the feeble-minded child has such 
a defective brain that it cannot be developed beyond a certain narrow limit, 
and represents arrested development. Let us understand that the backward 
child may be a slow-growing genius, and be perhaps the stronger for the 
fact that he grows so slowly. We have had evidence that some of our best 
men in history have been very slow growers in childhood. The backward 
child may be one for whom the school conditions under which he lives are not 
the proper ones. Our public school system is very much in need of improve- 
ment towards greater elasticity, so that the individual needs of the children 
may be better understood. At present, with certain exceptions, the school 
— and I do not mean the public school only, but the private school as well — 
measures all children very much by the same standard and does not rec- 
ognize the difference between types. There are certain types which in the 
wrong school environment will be backward, but which, if placed under the 
right influence, will all at once throw off the bonds and fetters and will grow. 
Therefore the problem of the backward child is a problem much more com- 



21 

plicated than that of the feeble-minded. The main study of all educators, 
with the help of the physicians, should be how to help the backward child, 
how to rescue the backward child and give the backward child his or her 
chance in life. You will see by the resume of the next paper, that the feeble- 
minded children constitute 3 per cent, of the entire school population. We 
may with a certain amount of justification say that the backward child would 
represent about 13-15 per cent, of the entire school population. That 
means that the problem of the backward child is even as far as numbers are 
concerned a very much bigger one than that of the feeble-minded child. 
Nevertheless, both are present in our public and private schools. It must be 
admitted that even the problem of the backward child is not easy of solution, 
that we are not able to say to what extent his difficulties can be relieved. 
There are so many different types and conditions that much study is needed. 
Every teacher, physician, and social worker will simply have to do what is 
in his power to bring this great problem before the general public and before 
the legislators. I read this morning that the longed for establishment of a 
Federal Children's Bureau has been effected. Its work may help materially 
in determining how many of the backward children, of the misfits in society, 
can be reached by educational, medical and social methods. 
Dr. J. B. Tuckerman, Cleveland: 

I have in mind a girl from a small country town in which there was no 
good oculist. The girl had a very high error of refraction, and steps had been 
taken to send her to a school for feeble-minded children, because she could 
not learn, and was so indifferent. The correction of the error made a very 
remarkable change in her. Although she was nearly 13 years of age, she 
had not reached more than a seventh year grade in school. I think we must 
be very careful not to commit a child as lacking in mentality, when there 
may be only a physical defect. This is particularly true when the physical 
defect is not that of hearing but of a high error in refraction, which makes it 
not only impossible for a child to see distinctly, but impossible for it to tell 
the difference between letters such as E or B. When the eye brings the up- 
right lines into focus the horizontal are out of focus, and vice versa. In this 
instance, a serious injustice would have been done this girl, had she been 
put into a school for feeble-minded. This brings out the fact that we have 
overlooked in our educational system a proper study of the developmental 
defects of children. 

Dr. H. M. Carey, Spring City, Pa. : 

The little that can be done for the feeble-minded in institutions must be 
begun early. Through the action which our Legislature has taken in connec- 
tion with the schools in this state, we now have in the majorities of the cities 
a corps of nurses, inspectors, and physicians working harmoniously with the 
state institutions, and the people in the institutions depend upon them to 
send the class of cases that should be seen early. It is not well to make 



22 

promises to parents of what can be done, but the fact should be impressed 
upon them that such cases require special training, and if anything is to be 
accomplished they must come under that training very early. I agree 
heartily with Dr. Groszmann's statement that the backward child is ex- 
ceedingly maligned by being classified with the feeble-minded. Much of 
our work is hindered because of the confusion of these two conditions. 

Dr. Cornell, closing: 

The thought I particularly wanted to bring out is that there should be a 
distinction between feeble-minded and backward. The principal confusion, 
I think, is one of terms. We never have had a definite series of terms upon 
which we all agree. Personally, I look upon all children who cannot do 
ordinary school work, as mentally deficient children. They are not necessarily 
feeble-minded, and not necessarily defective in every mental process, but they 
are deficient somewhere. This is shown in the public schools, the curriculum of 
which is graded to suit the average child. In the mentally deficient I separate 
those who are feeble-minded from those who are dull and backward. There 
is a border line, comprising many cases exceedingly difficult to diagnose. 
We have all seen cases of remarkable improvement under the right con- 
ditions. We should have special schools and institutions which provide for 
different grades of mentality or separate institutions. Idiots should not 
be placed with those of better mentality. The actual feeble-mindedness 
seems to be in about the same proportion among the foreign element as in 
the native-born Americans. 



II. 

METHOD OF SECURING STATE APPROPRIATIONS FOR 

PROPER SEGREGATION AND CARE OF 

FEEBLE-MINDED. 1 

By Joseph S. Neff, M.D., LL.D., D.P.H., Philadelphia, Director Public Health and 

Charities. 

I presume I was requested to bring this matter before the 
Conference, owing to the fact that the City of Philadelphia 
received an appropriation from the State Legislature at the last 
session. My experience, of course, is limited to this state, but 
experience, human nature and politics are the same elsewhere. 

We followed, to a great extent, the scheme used by Mr. John- 
stone, of Vineland, N. J., when he was successful, a few years 
ago, in securing an appropriation from the Legislature of that 
state for the institution of which he is superintendent. 

It is useless to endeavor to secure aid from those residing out- 
side of your district or city, until you secure the cooperation; 
the interest and enthusiasm of the local community; first through 
publicity, interest your philanthropists and social workers, then 
the local legislators and prominent politicians. The next im- 
portant step is to secure the interest of the Governor and the 
chairmen of the Appropriation Committees and each individual 
member of those committees. You must learn to know the men 
who finally pass upon the measure, whether they are independent 
of thought and action, or are absolutely controlled by others — in 
the latter event it is useless to waste time or writing material. 
Much time and effort is wasted on unimportant and dependent 
men. It is better to concentrate on the leaders and their in- 
fluences than spend too much time on the many — although 
all should receive at least the compliment of a circular letter, 
even if it does no good, rather than omit some little-known repre- 
sentative who may be offended by the oversight. Success in 
winning absolutely dependent members to your view avails noth- 
ing, if they depend upon the dictation of others for their final 

1 Read at the Conference on the Conservation of School Children, Lehigh University, 
April 3, 1912. 



24 

vote. First get your own community solid. Start with your 
associations organized for the general uplift, civic and religious; 
addresses should be made to them, showing the need for the proper 
segregation of the feeble-minded, the dangers existing without 
it. Show, whenever possible, the saving to the taxpayer; where 
the feeble-minded are uncared for, show the cost of maintenance in 
jail, reformatories, courts ; show their lawlessness, their being easily 
moulded for crime, the menace to the community in which they 
live, the rapid propagation of the species by allowing women of 
child-bearing age to remain at large, making an ever-increasing 
cost to the community. The cost is easily remembered, but the 
saving is forgotten. Then, with their aid, organize a local pub- 
licity campaign. Ascertain the leaders of the delegation to the 
Assembly, interest their family physicians, whose judgment they 
accept, and use personal effort of the best business interests on 
them individually. Through newspapers and local magazines, 
show individual cases, reports of hospitals and public institutions 
that center attention to the home town and bring facts to their 
own hearths. If the local delegation is not thus enthused and 
united in the movement, you cannot reach them by the influence 
of other sections, and it is useless to carry the campaign further. 
If they are now in favor of the measure, they must be supported 
by a state wide campaign, or at least by the support of their fellow 
legislators from other counties. Ordinary letters to these gentle- 
men, as a rule, are without avail; you must reach them through 
local interest of their particular constituents, those upon whom 
they are dependent for votes for their election. 

In the case of the feeble-minded, you must learn the number 
in their home district who are not properly cared for, applicants 
to state or private institutions. Now is the time to get in touch 
with families — the mother who has exhausted every effort to 
have her feeble-minded child placed in an institution — a child 
just as dear to her heart as her others, if not dearer, through afflic- 
tion. She must be informed of the request for the appropriation 
which, if obtained, may make room for her child, or, if a distant 
county, the crowded state institution of that section will be re- 
lieved by the removal of patients chargeable to the county seeking 



the ap*propriation, which may make a vacancy for her child. 
Have these individuals write or see their member of the legis- 
lature, to urge the appropriation, as they will directly benefit. 
It is needless to circularize the members themselves, until the 
session opens, as any mental impression made by such literature 
is apt to fade away, but then they should receive short pamphlets 
about every ten days, setting forth the different phases of the 
subject, statistics, the importance to the state, not dwelling 
too much on the conditions of your own city. These should 
be sent to the home and not to the state capitol, where they would 
find a rapid route to the waste paper basket, with the mass of 
literature on so many bills. In the home it may be read by the 
wife or daughter, who will certainly talk on the subject to the head 
of the family if it is well presented. 

Following the circulars, timed just before the matter is taken 
up by the Appropriation Committee, a personal letter should 
be sent the legislator, giving the individual names of those not 
provided for in his own bailiwick, and all detail, of which he al- 
ready has knowledge through the personal solicitation of the fami- 
lies and their friends, if your campaign has been properly carried 
on. 

So, when the matter comes up for final decision by the Ap- 
propriation Committees, there will be but few who have not 
detailed knowledge of the subject, and from a source they cannot 
ignore. After the bill is passed you must not relent in your 
eternal vigilance until it has received the signature of the Governor, 
for there is so much asked in excess of funds available that much 
influence is brought to bear for other matters. It is quite common 
for legislators to make a deal with each other to take away from 
measures already passed, to procure more for their own pet 
schemes that no one else is interested in, thus, by promising to 
work for the other's interest, to secure aid for themselves, so 
that quite strong cliques are formed. 

Then again, it at times becomes necessary for the Governor to 
cut appropriations, to bring them within the income of the state, 
and unless you are "on the job" you will be the one to suffer. 

This is the general outline; of course, there will be local condi- 



26 

tions, and combinations, especially for private institutions that 
must be watched, and the plan of attack changed accordingly. 

You must not forget that the leaders of thought and of political 
party must be unopposed, and should be not only with you 
for success, but must be kept with you, for, as the exigencies of 
a busy session arise, they are easy to lose at almost any time. 

One argument used against the appropriation was that it was 
"an unsafe precedent to make" an appropriation by the state to 
a municipality, which was answered by the statement that the 
most economical thing the state could do would be to make such 
an appropriation to every municipality which agreed to perform 
the moral duty of the state to care for its mental defectives, 
thereby taking from the commonwealth the cost of maintenance. 

My personal belief is that the state should perform its obli- 
gations to its own before it gives away a single cent to private 
charities, and the mental defectives are one of its most important 
obligations. When these are performed, then the balance of 
the income could be given away. 

Appropriations were made to private charities, as follows : 

1879 93. 500 

1889 750,000 

1899 1,250,000 

1909 5. 200, 000 

It is difficult to stop this abuse, for each representative is inter- 
ested in securing as much as possible for the private institutions 
in his own county, and make3 his deals with others by exchange 
of votes; if he is not successful, it comes hard for him to be re- 
turned at the next election. 

If, in the past twenty years, there had not been this tremendous 
increase in appropriations to private institutions, ample appro- 
priations, instead of skimped ones, would have been made to state 
institutions. Rittersville would have been opened six years 
ago, Spring City would be equipped for its full quota, and proper 
care given to this class of defectives, the burden to-day would be 
lighter, we would have a decreasing instead of increasing number 
of feeble-minded, which would make for a better level of physical 
strength and a higher grade citizen. 



27 
DISCUSSION. 

Dr. M. P. K. Groszmann, Plainfield, N. J. : 

Dr. Neff spoke of the appropriations to private charities in contra-distinc- 
tion for those which the state votes for its own needs for the feeble-minded 
and others. I think I know what he means and I agree with him, but I 
think he ought to be a little clearer in what is meant by these private charities. 
If they are doing the work which the state ought to do but does not do then 
they are positively deserving of state appropriations. Of course it is a bit 
ludicrous to find that the state appropriates to private organizations money 
which it should put to its own needs. This problem of whether appropria- 
tions to institutions are legitimately such which the state ought to make or 
whether they are fraudulently obtained is one which ought to be more fully 
investigated. Many of us know that a number of so-called private charities 
are simply pet schemes of people who have nothing better to do, while other 
private charities are doing work which the state should do. 

Dr. J. E. Tuckerman, Cleveland: 

I would like to inquire whether there is any way whereby we can ascertain 
whether these private charities receiving money from the state put it to the 
use for which it was appropriated. 

Dr. Neff, closing: 

I probably was not thoroughly understood. I do not oppose appropria- 
tion of state funds to private charities, but believe that the state should first 
give to its own institutions; when they are properly provided for any balance 
left should be divided among the private charities, but not before. In 
regard to fraud I would say that six or seven years ago there was great criti- 
cism of the distribution and expenditure of money to private institutions. 
The question was studied carefully by the state authorities, as a result of 
which every institution asking state aid was required to give a detailed de- 
scription of their institution, the number of beds, photographs of their wards 
and buildings. 

A special accounting department was organized in Harrisburg, and all 
hospitals receiving state aid, were compelled to keep their books in accordance 
with instructions from that accounting department. State auditors in- 
spected the accounts of the institutions quarterly and certified their correct- 
ness to the proper state official before payments were made. So far as I know, 
in recent years money appropriated by the state, to these private institu- 
tions, has been properly spent. I would not wish to be misunderstood in 
saying that these private institutions do not do some of the work that the 
state should do. To care for the aged and infirm is the county's duty and not 
the state, but care of the defective classes I believe to be the duty of the 
state. I am absolutely in favor of devoting every last penny of the state's 
income, after state institutions are provided for, to those private institutions 
which are worthy and do much good. 



III. 

HOW FAR SHALL THE PUBLIC SCHOOL SYSTEM CARE 
FOR THE FEEBLE-MINDED? 1 

By Andrew W. Edson, New York City, Associate City Superintendent of Schools. 

The feeble-minded children who should be in attendance at 
public schools are those children somewhat below par in mental 
acumen, possibly merely of slow development, yet susceptible 
of intellectual growth. Idiots and imbeciles are institutional 
cases, not public school charges. A careful examination by 
a specialist may determine if a child proposed for a special class 
is hopeless and should therefore be committed to an institution. 
A very large number of cases, however, must necessarily be those 
on the border-line between imbecility and merely slow develop- 
ment, cases that even trained experts find it difficult to diagnose 
with certainty. These are the children who by the right kind 
of training may improve intellectually in a very marked degree 
or who by neglect will soon sink into a hopeless and helpless 
condition. If educable, even to a limited extent, their place 
is in a special class in the public schools. 

Modern education emphasizes one principle clearly: Every 
child is entitled to all the education which he is capable of receiving. 
This principle applies to all children, not only to the great majority 
but to the mentally and physically handicapped irrespective 
of cost. The very fact of existence gives the child the right 
to a training that will lead him to be happy, self-respecting, 
and self-supporting. One very noticeable feature in the training 
of children is the fact that they are happy, or likely to be, when 
usefully employed. And while children of low mentality may 
never become leaders, may need oversight and guidance through- 
out their lives, yet if they have learned to use their hands to 
advantage, the elements of a trade possibly, they may be self- 
supporting, or at least less of a burden upon their families and 
upon the state by reason of the training received. This alone 
is enough to warrant the expenditure. 

1 Read at the Conference on the Conservation of School Children, Lehigh University, 
April 3, 1912. 



29 

The right of a child carries with it the duty of the state to pro- 
vide this training. A handicapped child is a great burden upon 
any family and is likely to be a menace to society. As an economic 
measure, therefore, the expense of an education should be borne 
by the state even if the per capita cost is heavy. 

The particular reasons why a child slightly sub-normal should 
be educated in the public schools, in school buildings with normal 
children, though not in classrooms with them, are: (i) This 
arrangement is an economic one. Taxpayers and members of 
boards of education are obliged to consider the expense entailed 
in any educational proposition, especially in one that is a decided 
departure from traditional usage. A suitable room in some 
school building can be secured easily and equipped at small 
expense. In some cases it may be necessary to consolidate 
classes in order to provide a room, even to put some of the younger 
pupils on part time, but it should be done. Part time is not a 
serious evil for pupils of the first year- grade. (2) The matter 
of travel to and from school is a serious consideration for feeble- 
minded children. Public school buildings are usually located 
near homes and are easy of access. (3) The opportunity to go 
to and from school with normal children, to associate with them 
on the playgrounds and in some of the general exercises of the 
school must be of the highest value to children of undeveloped 
mentality. Such association for a portion of the day must have 
a tonic influence upon them, a decidedly better effect than would 
the realization through complete isolation that they are set 
apart as dullards. (4) And the leading argument perhaps is 
based upon the fact that these feeble-minded children are of 
all grades of dulness, some of them but a little off from normal, 
cases of slow development it may be, and possibly behind grade 
in only one or two subjects. By having the classes of sub-normals 
in ordinary school buildings, the children may be allowed to go 
to regular grade classes at certain periods each day and in certain 
subjects in which they show the most interest and greatest 
aptitude. In this way many a child may soon be transferred 
permanently from the special class to the regular grade class 
gradually and naturally. 



3o 

A strong argument for the assignment of these exceptional 
children to special classes is the relief to the teacher and children 
of regular classes; a great burden is thereby lifted. 

In order to understand just how one city handles this question, 
I may be permitted to explain briefly the plan followed in the 
City of New York which has 120 classes of mental defectives 
in its public schools. 

In the first place the principal and class teacher make note 
of children who by their looks, language, or actions give indica- 
tion that they are peculiar — that they are freaks or unusually 
stupid. After a few days of special observation the following 
blank is filled out in regard to such and forwarded to the Inspector 
of Ungraded Classes as they are called: 

Observations on Children Proposed for an Ungraded Ceass. 

P. S , Borough 

Name Address 

Age .... Grade .... Nationality F M 

Years in U. S Home Conditions 

Health Records: Nutrition Bone Dis Enl. Gl 

Teeth Throat Nose Vision R L 

Hearing R L Nervous Disease 

School Records: Kn'dg. . . .terms iA terms iB terms 

2A. . . .terms 2B. . . .terms 3A. . . .terms 3B. . . .terms Spec'l. . . 

School att. Cause of Irreg. att Absence in last 

two terms Attention Memory Oral Exp 

Hand Work Phys. Tr Number Reading 

Writing Spec. Tastes Disposition Behavior 

Habits Peculiarities 

Other information 

19 . . Principal 

As soon as possible the Inspector and the Medical Examiner 
call at the school and make a thorough examination of the child, 
entering their observations upon the following blank: 



3i 

Special Medical Examination. 

P. S Borough , 

191 

Name 

1. General Condition 

A. Anatomical 

Cranium 

Facial Asymmetry 

Palate 

Teeth 

Tongue Lips 

Eyes 

Ears 

Limbs 

Skin 

Body in General 

B. Physiological 

1 . Motor Function 

Tics Tremors 

Epilepsy Nystagmus 

Promptness Coordination 

Prehension R L Gait 

Speech Fatigue 

2. Sensory Function 

Eyes R L Ears R L 

3. Condition of heart Pulse , 

1 C. Psychical , 

Balance Proportion 

Moral Sense Attention 

Memory Will 



Peculiarities 

D. Development-Att. Diseases 

E. Family History: Births 

Miscar Deaths 

Cause of Diseases F M. 



Medical Examiner 



Recommendation . 



Insp. Ungraded Classes 

If it is decided that the child is below par, he is sent to some 
ungraded class near at hand. Here in a class of from 10 to 15 



32 

pupils he is given individual attention with special emphasis 
upon physical and manual training. At every point an attempt 
is made to arouse his dormant energies, to strengthen his muscular 
and nerve powers, to cultivate self-control, and to strengthen 
his intellectual, moral, and esthetic faculties. 

A pedagogical record is made four times per year in order to 
enable the Inspector of Ungraded Classes to note possible im- 
provement. The following is a copy of the record sheet: 

Pedagogical Record. 

P. S Borough 

i9 19 

Name 

Sept. 20 Dec. 20 Mar. 20 June 20 Sept. 20 Dec. 20 Mar. 20 June 20 
Sense Training 

Taste 

Smell 

Touch 

Sight 

Hearing 

Physical Train, (imitation) 

Physical Train, (command) 

Writing 

Industrial Training 

Language (oral) 

Language (written) 

Reading 

Arithmetic 

Nature Study 

Personal Habits 

Self Control. 

Effort 

Gen'l Information 

Power of Attention 

Power of Memory 

Power of Judgment 

Gen'l Health 

Fatigue 

Attendance 

Teacher 

From time to time a medical re-examination is made as per 
the following: 



33 

Medical Re-Examination. 
P. S Borough 



Name 

General Condition 

Nutrition 

i . Motor Function 

Tics 

Tremors 

Epilepsy , . . 

Nystagmus 

Promptness 

Coordination 

Prehension, R L 

Gait 

Speech 

2. Sensory Function 

Vision, R E 

Hearing, R L 

3. Condition of Heart 

Pulse 

Throat 

Remarks 

Medical Examiner 

It is our purpose to select class rooms that are large, sunny, 
and easily accessible from the street and to the playgrounds 
and sanitaries. The special equipment is fifteen movable and 
adjustable seats and desks — fifteen being as large a number 
of pupils as can well be handled in a class — four shop benches 
and equipment, physical training equipment, a piano if possible, 
running waiter, and porcelain sink. 

The course of study is adapted to the needs of individual pupils, 
manual and physical training predominating. The greatest 
liberty possible is allowed teachers in adapting the present course 
of study for the grades to the needs of the individual members 
of the special classes. 

Our teachers are volunteers from the ranks, who are paid 
$100 per year additional. Many of them have taken courses 
at the Vineland Summer School, and, by observation, study, 
and experience, are growing to be skilled teachers in this particular 



34 

field. The fact remains, however, that but few teachers of these 
special classes are suitably prepared. If kindergartners need 
a two years' course of special training for their work, surely the 
teachers of exceptional children, where expert knowledge is 
required, need a course of special training of equal length. Any 
six weeks' course of special training is but a mere beginning. 

In general then it may be affirmed that the movement for the 
education and training of exceptional children in the public 
schools, one group of which is the feeble-minded, is spreading 
throughout our cities. It is one of the best aspects of modern 
education. The submerged tenth is beginning to come to its 
own, a right that it has always had but one not fully recognized. 

In view of the efforts and progress made, the success attained, 
and the light that has been shed on this problem, I beg leave to 
offer the following suggestions : 

i. In every city there should be a recognition of existing 
conditions. Sub-normal children — variously known as back- 
ward, dull, feeble-minded, or of slow development — are with us. 
They can be found if the school authorities and medical fraternity 
will but open their eyes and look about them. 

2. There should be established in each city a psychologic 
clinic, possibly in connection with the city hospital, under the 
control and direction of the Board of Education, for the purpose 
of examining and classifying all children deemed by the teachers 
and school physicians as somewhat peculiar, below normal, 
exceptionally dull. At this clinic the degree of mental deficiency 
should be determined by scientific methods; full and accurate 
records of school work, home conditions, and hereditary data 
should be obtained and filed; and a proper assignment of each 
case should be made, some to school, to particular phases of school 
work, and others should be remanded to state institutions as 
custodial cases. 

3. Suitable classrooms in regular school buildings should be 
secured for these children, and suitable equipment provided. 

4. The classes should be small, not more than 12 or 15 in a class, 
in order that these children may receive individual instruction. 

5. Specially qualified teachers, who have a natural aptitude 



35 

for the work, should be selected — teachers who have infinite 
patience, tact, resourcefulness, intense human sympathy, an 
appreciation of effort, and unbounded faith in the young people 
entrusted to them — teachers who are students of the latest litera- 
ture on the subject, which is abundant, and who make frequent 
visits to schools where instruction to exceptional children is 
given. 

6. The management should be kind and sympathetic. I^ove, 
sympathy, and a cheerful attitude will lead these children — or 
any children for all that — far better than nagging, threatening, 
or punishments. 

7. A suitable course of study should be provided — a course 
that gives emphasis to the essentials, that is flexible, and is adapta- 
ble to the needs of the individuals, a course that leads directly 
to some vocation. 

8. The instruction should be personal and individual, and 
should give emphasis to physical and manual training, to nature 
study, excursions, and illustrative material. The much-talked 
of Montessori method is undoubtedly well worth a careful study 
by teachers of feeble-minded children. 

9. In this work the skilled teacher and skilled physician should 
labor side by side. Many of these children have serious physical 
defects that should be remedied as soon as possible. The training 
should be corrective and curative, physical as well as intellectual. 

10. And, if the school authorities do not do their duty towards 
these unfortunate children, if lack of funds or lack of interest 
is in the way, people of means and warm hearts should be appealed 
to to see that this work is done. 



IV. 

HOW FAR SHALL THE PUBLIC SCHOOL SYSTEM CARE 
FOR THE FEEBLE-MINDED? 1 

By James H. Van Sickle, Superintendent of Schools, Springfield, Mass. 

The opinion is gaining ground that the care of the positively 
feeble-minded, like that of the insane, is a state function and not 
one for local communities. Few states have yet made adequate pro- 
vision for the care of the feeble-minded, consequently for the 
present most cities and towns must do what they can independ- 
ently till the state is ready to carry the full burden. The public 
is slow to realize the extent and gravity of the problem. One 
of the most competent authorities places the number of feeble- 
minded in any community at 3 to every 1000 of the general 
population. These are individuals who cannot sustain themselves 
in competitive industry. They remain children all their lives 
—children in intellect and will, though adults in stature and in 
instincts. 

Boys of this class if left to themselves are likely to drift into 
criminality. Being too inefficient to secure steady employment, 
a life of criminality proves the path of least resistance for them 
and they soon come upon the state for support in our penal 
institutions. We know that large numbers of the inmates of 
our jails and prisons are mentally defective. At the expiration 
of their terms they are again thrown out upon the community 
no better able than before to sustain themselves honestly, and 
with even less will to do so. Out of prison as well as in prison 
they are a public charge. 

The feeble-minded girl if unprotected is a still greater menace 
to the community. While there are feeble-minded children born 
into good families, such cases are sporadic. They amount to less 
than 20 per cent, of the whole number. Eighty per cent, of the 
feeble-minded are so by inheritance. To prevent the marriage 
of feeble-minded girls and to shield them from temptations to 

1 Read at the Conference on Conservation of School Children, Lehigh University, 
April 3, 1912. 



37 

which they are notoriously easy prey is obviously the duty of 
society as a plain matter of self-defense. 

What can the schools do? The public school is one of our 
social institutions and as such it may justly be expected in work 
with the feeble-minded to do whatever its publicly provided 
facilities permit it to do without neglecting its other functions. 
Some of the things it can do in this direction are as necessary 
for the protection of the normal children as they are advantageous 
to the feeble-minded themselves. Each type needs instruction 
different from the other. The school can gather the feeble-minded 
into groups for special treatment and care, and it must do so 
much in the interest of normal children whose progress the sub- 
normal impede if retained in regular classes. Furthermore, 
since the obscene and indecent acts which teachers sometimes 
have to correct are almost invariably committed by mentally 
defective children, the school organization should see to it 
that normal boys and girls are protected as far as may be from 
association with those whose sense of decency is lacking. 

While feeble-minded boys are within the usual compulsory 
attendance age, they are not a menace to school or society if 
taught in separate classes. It is when they are 14 to 16 years 
of age or over that they become a menace. The feeble-minded 
girl may become a menace several years earlier. The public 
school cannot, therefore, with safety retain feeble-minded children' 
very long without a radical addition to present means for their 
care in the form of residential homes or colonies with farm, garden, 
shop and productive industry such as are now provided only by 
the state. There must be separate homes for boys and girls 
to which they should be legally committed for life. This would 
not, of course, be necessary where the feeble-minded boy or girl 
has a good home and reliable parental protection. It would, 
however, be necessary in a very large majority of the cases. 

It has been suggested that if parents are unwilling to have 
their children transferred to such a colony after they have ex- 
hausted the resources of the special public school classes and have 
left school, that the feeble-minded may be guarded by teachers 
or probation officers who keep watch of them at their homes, 



38 

and upon any indication that they are going wrong or becoming 
in any way a menace to society, take immediate steps to have 
the state interfere and take such children to the colony home. 
Should society adopt this plan of self-protection, the school 
might properly be called upon to aid, since the teachers of the 
special classes are the only ones who know intimately the charac- 
teristics of the children in question. At any rate, it is manifestly 
important to have all sub-normal children, except idiots, attend 
school during their earlier years, if only for the purpose of being 
studied. Some thus studied prove to be only backward or slow 
in developing and may safely be returned to the regular classes 
after time and special help have cooperated toward improvement. 
Specialists expert in this work find it impossible to determine, 
except after long observation extending in many instances over 
several years, whether a child is feeble-minded or merely backward, 
hence, the special class in the public school serves its most useful 
purpose as a clinic in which suspected cases are slowly and care- 
fully diagnosed. The mental condition of a child should, however, 
be determined as early as possible, certainly within the first two 
years of his attendance at school, lest habits of inattention too 
bad to be corrected be formed, and lest he become chronic in 
never accomplishing anything. These children are in special 
need of the inspiration of success. This they get in the special 
class where the tasks set are within the grasp of their feeble 
powers. 

The teacher of the special class should be equipped not only 
with technical knowledge of mental defects, but with ability 
and willingness to enter into sympathetic and friendly relations 
with parents of feeble-minded children, gradually and gently 
acquainting them with the child's real condition and of the ad- 
vantages which the state colony offers, and finally securing their 
consent to a transfer to the institution. The most delicate and 
individual work is required here, and the teacher who under- 
takes this service must be an exceptional person. One such in 
any single city, except perhaps in a dozen of the largest, would 
probably be sufficient, since other teachers with less scientific 
preparation could serve in auxiliary centers under the guidance 



39 

of the single expert. Teachers of regular classes should call 
the attention of the specialist to suspected cases. These specialists 
should observe in their rooms and advise for or against a transfer 
to the special class. 

The school physicians and other physicians of the community 
and social agencies of various sorts should be drawn into coopera- 
tion so that each child may be put into as good physical condition 
as possible — his teeth mended, his defective eyesight aided by 
glasses if necessary, his body nourished by food and protected 
by clothing, either at public expense or by philanthropic endeavor. 
Hygiene, exercise and manual industry should be the prominent 
features of the schooling of these children. The ordinary curricu- 
lum should be in evidence only incidentally. The public school 
will render its greatest service in fitting these positively feeble- 
minded children, as far as may be, for self-support under close 
supervision in some of the simplest industries that can be carried 
on in colony homes, and in sifting the human material that it 
handles so that the various elements will reach their proper 
goal, this goal being life in society for the curable cases, life under 
protected conditions for the incurable. 

Another service which the public school can perform is that 
of acquainting the public with the gravity of the situation and 
the need of greatly increased facilities for dealing with the growing 
menace of the feeble-minded. To this end it is important that 
permanent records be kept which will afford cumulative evidence 
of a convincing character. Such records have been kept in Spring- 
field. During the past six years, thirteen pupils have gone from 
the class to the state institution at Waverly, sixteen have regained 
their places in the school grades, three have entered parochial 
schools, eleven have moved away, and eighteen are regularly 
employed. Twenty-nine have had physical defects remedied. 

In the words of Dr. Fernald, of Waverly, Mass., from whom 
I quote: 

The one great deduction from sixty years' experience in the education 
of the feeble-minded is that under the best conditions only a very small 
proportion even of the higher grade cases become desirable members of the 
community. They need protection and care, and the family and community 



40 

should be protected from their certain tendency to drift into pauperism, 
prostitution and crime. 

It should be remembered that under the most favorable conditions 
hitherto, a very large proportion of feeble-minded persons, even of the higher 
grades, eventually become public charges in one way or another. No one 
familiar with the physical and mental limitations of this class can believe 
that any plan of education will ever materially modify this fact. Any relief 
as to public support to be obtained from public school training can be only 
temporary. Feeble-minded children may be tolerated in the community, 
but it is a great responsibility to inaugurate any plan on a large scale which 
does not withdraw from the community the defective adults. The feeble- 
minded are powerless to resist the physical temptations of adult life and 
should be protected from their own weakness. 



HOW FAR SHALL THE PUBLIC SCHOOL SYSTEM CARE 
FOR THE FEEBLE-MINDED? 1 

By E. Bosworth McCready, M.D., Medical Director, Hospital-School for Backward 
Children, Pittsburgh, Pa. 

Upon the elimination of the various classes of defectives from 
the competition of every-day life depends the solution of many 
of the problems confronting the sociologist of the present day. 
There is no class of defectives who exert a more baleful influence 
upon the social body than the feeble-minded. Harmful though 
this influence is, the feeble-minded individual is so, through no 
fault of his own, and is as much entitled to our commiseration 
and care as any other unfortunate. Since the pioneer labors 
of Pereire, Itard and Seguin, the question of the education of 
the feeble-minded has assumed a very great importance, which 
has increased with the growth of our public school systems and 
the adoption of compulsory education laws. The feeble-minded 
child is as much entitled to the education suited to his needs 
as is the normal child. Though his limited faculties will never, 
under any system of education or training, enable him to ex- 
ercise the amount of judgment and discrimination necessary 
in even the ordinary affairs of life, yet it is surprising the high 
degree of efficiency which some will attain in certain directions 
under proper supervision. It is only through congenial occupation 
whatever that occupation may be, usually along manual rather 
than scholastic lines, that the feeble-minded child may be led 
to his fullest development and at the same time be given his 
maximum of happiness. 

The period between the ages of six and fourteen is the most 
important in the life of the feeble-minded child. It is during 
this period that he is able to make the best use of the special 
training which he requires. For this reason early recognition 
of his condition is necessary. Feeble-mindedness is often not 
suspected until the child by his inability to advance in school 

1 Read at the Conference on Conservation of School Children, Lehigh University, 
April 3, 1912. 



42 

gives evidence of his condition. Parents very often either cannot 
or will not see that their child is any different from other children. 
Sometimes they fail to bring to the attention of the family physi- 
cian the apparent abnormalities of the child, but the family physi- 
cian himself is very often at fault in this matter as he is very 
likely to lightly dismiss the subject with the remark that the 
child will outgrow his difficulty or that there will be a change 
at three years or at seven or at fourteen. In this way valuable 
time is lost which might be put to good advantage. It therefore 
devolves upon those who come into contact with the child in his 
early school days to recognize the importance of the situation 
and to take steps to remedy it. 

The question of the responsibility of the public school to the 
feeble-minded child should be considered in relation: 

i. To the child himself. 

2. To his fellow pupils. 

3. To society in general. 

In the ordinary class-room the feeble-minded child gains but 
little of value. It is true that some, in whom memory is well 
developed, will advance, but they gain practically nothing ex- 
cept the ability to repeat, parrot-fashion, dates, rules and formulae, 
understanding but little of their real meaning. Lacking pri- 
marily in the power of attention and unable to concentrate for 
but a short length of time the long school periods become irksome, 
and they soon become fatigued and restless. The feeble-minded 
child is suggestible to a marked degree. He consequently learns 
easily evil habits which in his more normally poised school-mate 
are little more than incidental phases of development without 
permanent damage, but in him tend to aggravation of his condi- 
tion. He also is liable to become the scapegoat for escapades 
of his companions and to be led even into law-breaking without 
any realization of the gravity of his offense. I have at the request 
of probation officers of the Juvenile Court examined a large number 
of boys who have been arrested on charges of theft and other 
crimes who were entirely incapable not only of understanding 
the gravity of their offense but of originating the plans by which 
the crime was carried out. In the majority of cases the real 



43 

culprits escaped. The feeble-minded girl is doubly in danger. 
How great her danger is, the records of any Juvenile Court will 
show. It is unfortunate that these girls are very often attractive 
in appearance and manner, and while their tendencies may not 
necessarily be immoral, their power of resistance is very slight 
indeed. It has been shown that a large proportion of girls leading 
immoral lives are feeble-minded. 

Mal-nutrition and a lack of bodily tone, with lessened resis- 
tance to disease is practically the rule in the mentally deficient. 
It has been noticed that whenever there is an outbreak of any 
of the acute infectious diseases in a school that the feeble-minded 
are always the first to succumb. On account of limited oppor- 
tunities for contact with other children and unusual solicitude 
on the part of the parents the feeble-minded child is often re- 
markably free from diseases until he begins to attend school, 
when he contracts one illness after another. The tendency to 
the development of tuberculosis is marked. In fact, this disease 
is the greatest cause of mortality. 

In the special or ungraded classes which are now a part of the 
school system in nearly all of our large cities the feeble-minded 
child may and usually does progress up to a certain point. I am 
firmly of the opinion, however, that the feeble-minded child 
should be allowed to remain in the special class only a sufficient 
length of time for his condition to be accurately diagnosed, or 
until a place can be found for him in a suitable institution. The 
partially educated imbecile is a far greater source of danger than 
the uneducated. To the casual observer he presents every ap- 
pearance of normality, consequently the same is expected of him 
as of the normal individual. If given a position when he leaves 
school, he soon shows his incapacity, and is discharged only to 
repeat the process until either having gone the round of avail- 
able employments or given up the battle, he joins the army of 
the unemployed and becomes either dependent or delinquent. 

In New York City "of fifty children formerly in the ungraded 
classes, chosen at random from many cases which have been fol- 
lowed up, there are two who are doing work more or less steadily. 
The others have been in constant difficulty in one way or another 



44 

since leaving school, are known to be immoral, have been arrested, 
have been in institutions and withdrawn, are known to be the 
means of corruption of other children with whom they come in 
contact, or are known to have incendiary tendencies." 1 

Of what advantage, except to the normal children and the 
teachers of the normal children, has it been to attempt to educate 
these in the special classes of the public school? They are no 
more fitted to participate in the world's work, than they were 
before, they are more dangerous to their fellows, less happy, 
their evil tendencies greater, their powers of resistance less. 
They have lost valuable years during which they have added 
their quota of misery and debt, to increase as each year goes on, 
and to no purpose. 

The influence of the feeble-minded child upon the other children 
in the class is bad. One such case can upset the discipline and 
impede the progress of an entire class. All children are highly 
imitative and from amusement at grimaces and grotesque actions 
they soon come to imitate them. The moral obliquities of the 
feeble-minded are also a source of contamination to the other 
children. To include the feeble-minded in special classes with 
those who are only backward is an injustice to the latter. The 
backward child is capable of more or less rapid advancement 
to normal under suitable conditions and when given the advantage 
of proper individual attention. It is impossible for the teacher 
to give this attention when her time is taken up with the feeble- 
minded. 

I have already alluded to the increased susceptibility to the 
acute infectious diseases and to tuberculosis. For this reason 
the feeble-minded child may become at any time a dangerous 
source of infection. 

I believe there is no one at this date, who will question the 
advisability of segregation for the feeble-minded of all grades. 
It is only in a suitable institution that the feeble-minded individual 
may lead the wholesome, contented and often useful existence 
to which he as a human being is entitled. 

The feeble-minded individual at liberty is almost always a 

1 "Feeble-minded as City Dwellers," Eleanor Hope Johnson, The Survey, March 2, 1912. 



45 

burden and often a menace to society. If it were possible to 
figure up the number of murders, sexual crimes, incendiarisms, 
and thefts committed by this class of persons, the result would 
be appalling. The only remedy is segregation. "Feeble-minded 
children and feeble-minded men are roaming about the streets 
to-day as free agents. Parents are not compelled by law to put 
a feeble-minded child in custody, yet that feeble-minded child 
unsuspected as such, amiable, care-free as he frequently is, 
is potentially a criminal and at any moment may commit a crime. 
That child is permitted to grow up without restraint, except 
such as parents exercise, and this has no effect whatever in these 
cases. The child is allowed to marry and bring forth children 
of his own kind, more feeble-minded, more dangerous. There 
is no system designed to pick out from the community persons 
so affected, and no law whatever to prevent their untrammeled 
movements." 1 Our institutions are totally inadequate to pro- 
vide for more than a small proportion of those requiring their 
care. It is true that to erect sufficient institutions to adequately 
provide for the immense number of feeble-minded would be 
a severe tax upon the public purse. But the expense would soon 
prove to be a matter of economy. Quoting from a recent editorial 
in The Survey: "the feeble-mindedness which fills the almshouses 
to overflowing, recruits the jails and prisons, clogs the reforma- 
tories, furnishes victims to the white slave traffickers, and inter- 
mingles unhindered with healthy strains to gain a new vitality 
and to extend its blight to hitherto untainted families — this 
feeble-mindedness which is obvious, obtruding itself whether 
we like it or not upon public notice, laughing to scorn our penny 
wisdom by imposing its pounds sterling of foolishness on every 
taxpayer, this surplus feeble-mindedness, we must drain off 
as the true human conservationists are showing us how to drain 
it, by providing adequately for all who will voluntarily accept 
custodial care, and for those who are dangerous to their neighbors, 
even though it means compulsion." 2 I would go a step further 
than this and recommend compulsory custodial care, or perhaps 

1 The Survey, March 2, 1912. 

2 "Feeble-minded Boys and Crime." Max G. Schlapt, M.D., The Survey, March 2, 1912. 



4 6 

in some exceptional cases official supervision of all individuals 
known to be feeble-minded. What segregation can accomplish 
in the course of a comparatively few years has been demonstrated 
in Aosta in Northern Italy where the cretins who formerly abounded 
were segregated in 1890. By 19 10 only a single cretin of sixty 
years and three demi-cretins remained. 1 
Conclusions : 

1. The public school is not the proper place for the education 
of the feeble-minded. 

2. Careful examination should.be made by competent investi- 
gators of all children when first they apply for admission to the 
public school. 

3. Those found to be feeble-minded should be excluded and 
segregated in institutions. 

4. Doubtful cases and those backward in their development 
should, after the correction of physical defects, faulty environ- 
mental conditions etc., be admitted to special classes where they 
will receive the training suitable to their individual needs, and 
be under the observation of physicians especially trained in this 
sort of work 

DISCUSSION. 

Dr. Wm. G. Schauffier, Lakewood, N. J. : 

Mr. President, ladies and gentlemen, it is rather a difficult subject to try 
to discuss three such papers. Usually one paper is all that one man can 
digest, and talk about. The three papers which we have just heard deal 
almost exclusively with the actually feeble-minded children. I thought a 
discussion of backward children would have been included. I think there 
can be no question at all of the conclusions reached by the authors as to the 
actual feeble-minded children in our communities, and their need of segrega- 
tion. That they do better in their own physical lives under such conditions 
there can be no doubt. We cannot hope to do much for their mental con- 
dition. By their segregation, the menace to the community is done away 
with. There are conditions, however, that make it impossible to carry out 
the conditions that the readers of these papers have laid down. In the first 
place none of the gentlemen have spoken of the parents. The parents of 
feeble-minded and backward children, in their own eyes, at least, have just 
as much right to say what shall be done with these children as the physician 
or educator. Parents have rights whether they are ignorant or otherwise, 
1 "Heredity in Relation to Evpen," Daugenicsort, p. 259. 



47 

and the state cannot go into the home and say that the child is on the border 
line and must go to an institution, and — if we would go by what some have 
said — stay in an institution all their lives in order to avoid being a menace 
to the community. We are not ready for that yet. The question before us 
is, what can the state do under the existing circumstances? We have heard 
what cities can do, and while cities form a large part of the state and control 
the education of a large proportion of the children, yet there are the rural 
districts that we must take into consideration, and to my mind, the danger 
in the rural districts is almost as great if not greater than that in the cities. 
The cities have highly organized facilities for correcting the evils ; in the rural 
districts this does not prevail. In some rural districts it is even hard to find 
a medical inspector. How then can these children be examined? In New 
Jersey in the rural districts we are finding it extremely difficult to take up 
medical inspection. We have a compulsory medical inspection law which 
makes it obligatory that every school district shall appoint a medical in- 
spector. This has been in existence for three years and I happen to be at 
the head of our Board of Education, but we cannot yet enforce it in all our 
rural districts simply because we have not doctors enough to take up the work. 
That being so, what are we going to do? To my mind, the first thing is to 
find out who these children are, and then do the best we can under the circum- 
stances. A year ago a law was enacted in New Jersey making it obligatory 
on the State Board of Education to make a census of backward children 
throughout the grades of our public schools and to provide these backward 
children with proper training. We have been nine months at work. As 
yet we have not found it possible outside of the large cities to do much in 
that line. Jersey City and Newark have special classes but in the rural 
districts it is as yet impossible to have them. We are just perfecting a 
system which we hope will do something. I am glad to give an outline of 
our plan for your help and criticism. In the first place we have had to 
determine in a very general way who are the backward children. Our law 
reads that children three years behind the normal must be provided for in 
special classes not to exceed fifteen. When there are ten or more such children 
in a district it shall be necessary to provide a special class with a special teacher 
for them. A card system has been prepared. Cards are in the hands of the 
teachers which show the whole number of children in the school and the 
number of years they have been in attendance. The system works out in a 
step-like arrangement and it can be seen at a glance how many children have 
been in one class more than three years. These reports are sent to the super- 
vising principal, county superintendents, etc. The children found to have 
been more than three years in one grade are examined and the feeble-minded, 
merely backward, and the physically disabled are looked after separately. 
We have asked for cooperation on the part of Drs. Johnstone and Goddard. 
We have only one institution for the feeble-minded in New Jersey, and only 
one for the epileptic and these are overflowing all the time. Therefore we 
are much in need of means for providing for all these unfortunate children. 



4 8 

Miss Eleanor Johnson, New York City: 

I think Dr. McCready has suggested something that looks like the millenium 
to most of us — an ideal condition which is far in the future. These children 
are all around us and the public schools have room for them, as has been 
shown. There is no more room in existing institutions and if there were 
there is no way of compelling parents, who more often than not are un- 
willing, to send them there. When the children are in school, the parents 
at least know where they are. There is one statement I should like to ques- 
tion; it is concerning the danger that results from teaching such children. 
The teaching that is given is, as should be, largely manual training. Feeble- 
minded children are less troublesome and happier when occupied. They 
are taught how to draw, how to use their hands, and as a result they are more 
apt to be occupied when at home and so less likely to get into trouble. I 
know of one boy, a high-grade imbecile, who has become quite expert in 
carpenter work. He never can support himself without constant super- 
vision, because he is too subnormal to deal with commercial conditions, 
but he is perfectly happy in doing this wood work and can be made extremely 
useful. Until we can get proper institutions and enough room for these 
children, we must do something for them in the schools. The social service 
side of the public school work is very valuable just as it is in the hospitals. 
Let us have social workers as a part of the school staff. Much good can be 
done by their visits to the homes of the children, where they may teach the 
parents how best to care for mentally defective children. The only way 
at present by which we can hope to place children where they belong, is to get 
the parent's good-will. The social worker can often do that by repeated visits 
which the teacher has no time to make. The social worker can also follow 
up these children after they leave school and find out ways in which the 
school training may be made of more value to the sub-normal child. A 
better knowledge of the numbers of such children and their conditions can 
also be arrived at. In this way we shall more nearly solve the problem as 
it exists. 

Dr. L. L. Button, Rochester: 

One point not yet discussed is the great advantage accruing to the normal 
child when his grade is relieved of the influence of sub-normal child. The 
sub-normal child does hinder the advance of the whole grade. Then too the 
teacher has not been mentioned. She tries hard to bring the sub-normal 
child up to the standard. This is not possible and the whole grade is affected. 
It seems to me that a very great advantage that we have in the use of the 
public school classes for educating these children is that we can also use them 
as a clearinghouse in the getting of children of this type placed in institutions. 
It is true that the teachers in these classes get a better hold on the parents 
than one realizes until he has done this work. They gain the confidence 



49 

of the parents, and their advice that this child should be put into an institu- 
tion will be more readily accepted than that of any one else. In most cases 
where these classes are maintained they have medical inspectors who try to 
have removed as far as possible all the physical handicaps of the children. 
There is something that I would like to see brought about in connection 
with their work and that is a supervision of these sub-normal children when 
they go out into the world. I think there should be some kind of official 
control of their conduct and life for their protection. They are not able to 
control themselves well and they generally do not have good parental con- 
trol. If something like this were brought about their lives would be more 
useful and more happy. Too often they are simply the tools of unscrupulous 
persons. 

It also seems to me that the time must come when a child by reason 
of his mental deficiency cannot be supported by the family and is for this 
reason put under the care of the charity board; or in cases where the child 
has done some criminal act and the state has to interfere either to aid or 
correct, then it seems to me the state ought to have the right to interfere 
in the matter of segregation or asexualization for the benefit of the com- 
munity at large. 

Dr. Groszmann: 

I would like to call attention to the fact that the discussion of this sub- 
ject is being obscured by the confusion of terms, as Dr. Cornell has said. 
Dr. Cornell has been using the terms "dull" and "backward" in a way 
that perhaps others would not use them, but according to his own individual 
method. Again he thought it desirable to make distinctions among the 
children who are backward, but not defective. Dr. Edson has also con- 
fused terms. He has been using the terms "feeble-minded," "a degree of 
dulness," "a little sub-normal," etc., somewhat interchangeably. I am 
really not quite sure what kind of children he had in mind. All this shows 
that the various workers in this field have been using terminologies and 
classifications of their own, and there has not been yet an agreement upon 
terms and classifications. I do not consider it a presumption on my part to 
call attention to a classification which I presented in 1909 at a meeting of 
this Academy in Atlantic City. The subject was well discussed at that time 
and we tried to agree upon a classification and terminology upon which we 
could base our discussions. Otherwise we shall never understand each other. 

Regarding what Miss Johnson has said in criticism of Dr. McCready's 
paper, I should like to say that these ideals have to be expressed. What 
we have to do in order to gradually bring them into existence is another 
matter. I can assure you and encourage you by saying that a number of the 
things which I suggested ten or twelve years ago, and which were considered 
impossible then, have been demonstrated to be practicable in the public 
school systems of many cities to-day. 



5o 

Dr. H. M. Bracken, St. Paul, Minn. : 

I have heard the terms feeble-minded and backward used in such a 
promiscuous way this afternoon that 1 feel constrained to say a word. We 
should consider feeble-minded and backward children in the same group, 
and the term sub-normal is unsatisfactory. We can divide defective children 
into two groups: physically defective and mentally defective. The 
physically defective will include the deaf and dumb, the deaf, the blind, 
those with imperfect vision, and those low in physical condition, as in tuber- 
culosis and the anemic. What you should do with these children, so far as 
the public school is concerned, is an open question. You may provide for 
them in special classes; for some in graded or ungraded classes. We may 
divide the mentally defective into four groups: the idiot, the imbecile, the 
moron, and the dull. You may go further and include the epileptic. Now 
the epileptic, the idiot, and the imbecile should all be cared for in institu- 
tions as I understand it. The moron is an uncertain quantity and there 
should be a clearing house for such. He may be cared for in the public 
school under certain conditions. Medical inspection will help greatly in 
finding the place for the moron. The dull child may be classified as be- 
longing to the backward and he can very properly be cared for in the public 
school under proper conditions. The laws of New Jersey have been re- 
ferred to and the backward child grouped among those who have been in the 
grade three years or more behind the normal. This may include children 
who are backward because of defective sight or hearing in whom such defect 
has not been discovered. It is not fair to consider such children as mentally 
deficient. We should be very careful to group children properly. 

Dr. J. E. Tuckerman, Cleveland: 

I think the last speaker did not understand that Dr. Groszmann's classifica- 
tion was a tentative one, for the purpose of getting a line on those children 
who are not making the progress they should in their studies. 

Miss Johnson : 

I think my remark concerning the millenium was not understood. It 
was not made in criticism of Dr. McCready's paper. I think he has outlined 
something in which we all very much believe, and which we would be de- 
lighted to see brought about, but there seems to be immediate things which 
have to be attended to now. 

Dr. Edson, closing: 

I wish to say in reference to the attitude of parents in re the education of 
children of low mentality, that in our city parents invariably prefer the 
public schools to private or state institutions, as thereby they are assured 
of suitable instruction. Many parents insist upon the attendance of children 



5i 

at the public schools even when they ought not to be there. It is a difficult 
matter sometimes to keep children away from the public schools, when it 
is clearly evident that they ought to go to institutions. 

In regard to terminology, I agree that in speaking of mental defectives 
we should make a clear distinction between those children capable of in- 
tellectual advance and those not. In the case of the latter their place is 
not in the public schools; the public schools ought not to be burdened with 
them. When children are capable of improvement, they are more likely 
to be able to make a livelihood later on if educated and trained, especially 
in manual and physical lines, than if not. That they may be more of a 
menace if educated than if ignorant ought not to deter us from giving the 
proper training. They should be given as much education as they are capable 
of receiving, physical, intellectual, manual, and moral. To be sure we have 
a number of children in our city schools not capable of intellectual imorove- 
ment, because of the fact that as yet there is no other place to send them. 
We often have requests from the parents not to refuse admission of their 
children in the schools. I have in mind one child who has been in the schools 
for a number of years and receives no benefit, but in this school we have 
plenty of room and therefore allow her to remain. 

I think the harm to normal children in associating with children of low 
mentality need not be serious, provided the deficient children are in a room 
by themselves and under close supervision. We have two people, an in- 
spector and a physician, who are giving their time exclusively to examining 
these children and in classifying them in a tentative way in the public schools. 
We have made a good beginning. We have had these classes for eight or 
ten years. We feel that it is a work thrust upon us. These mental de- 
fectives ought to be followed up after they leave school, lest they be led 
astray. A large proportion of those who come to us receive some consider- 
able benefit. This statement cannot be challenged. 

Dr. Cornell, closing: 

There are two points to which I want to refer: (i) That when the proper 
kind of institution is secured for these children the problem will be largely 
solved. Provision should be made against crowding together the high-grade 
feeble-minded with the idiots. (2) We have heard so much of medical 
inspectors not being properly trained that I want to call attention to a ten- 
day course of instruction at Vineland for physicians taking up the work re- 
quired of medical inspectors 

Dr. McCready, closing: 

1 am very much in favor of the special class, but I do think, and very 
strongly think, that the special class for the feeble-minded is simply a com- 
promise. Parents of feeble-minded children would of course prefer to have 
their children entered in the special class. It would then appear that they 



52 

are backward and for that reason are receiving some special attention. There 
would be attached no suggestion of feeble-mindedness. While it is not 
dangerous to the imbecile himself to be educated I regard the education of the 
feeble-minded anywhere but in the institution as another compromise. He is 
sent out into the world and to the ordinary observer appears to be normal, 
because most people do not think or know about these subjects. They think 
if persons can read and write and talk sensibly at times that they cannot 
be feeble-minded, yet we may have a feeble-minded child go through all the 
grades and come out feeble-minded, slipping through his examinations. So 
long as we have the compromise of the special class we shall not get 
appropriations and we shall continue to have the problem of degeneracy, 
crime, etc., to confront us. We should examine each child as he comes into 
the school and take steps to segregate him. In this way the problem will 
be solved in the course of a few years. 



VI. 

STERILIZATION AND SEGREGATION. 1 

By Henry H. Goddard, Ph.D., Director Department of Research, The Vineland Train- 
ing School for Feeble-minded Children, Vineland, N. J. 

Many persons ask how does it happen that the feeble-minded 
child has so suddenly come into prominence? Has he so suddenly 
increased in numbers as to become a social menace or is it merely 
a fad of a few enthusiasts, who have become over-excited on the 
question? The answer is easy. The feeble-minded person 
we have had always, but under the former regime, the problem 
largely took care of itself because the feeble-minded person being 
neglected, the law of the survival of the fittest eliminated large 
numbers of them. But in the last half century, we have come 
to extend our humanity and feelings to these defectives. We 
have established institutions and schools for their care and 
training. 

Secondly, the compulsory education laws have brought these 
children to our attention by bringing them into the public schools. 

Our attention once turned to them, we have begun to investi- 
gate the situation and have quickly found certain startling facts. 

First, we have recognized that a great many children whom 
we had formerly thought to be wilfully bad are actually mentally 
deficient and unable to do well — to do differently than they 
do. 

Secondly, there has been discovered some remarkable methods 
of testing the intelligence of children and showing us that many 
of them are below par. The results of these investigations have 
shown that at least 2 per cent, of the children in our public schools 
are mentally defective and incapable of taking their place in society. 
To show what this means, one has only to take an example. 
Applying this ratio to New York City, we would find that there 
are 15,000 feeble-minded children in the public schools of that 
city and this figure has been amply verified by other means and 
by observation. Furthermore a careful study into the causes 

1 Read by title at the Conference on the Conservation of School Children, Lehigh 
University, April 3, 1912. 



54 

of feeble-mindedness has shown that it is very largely hereditary, 
at least two-thirds of the cases being the children of feeble-minded 
parents or grandparents or both. 

Still again the Royal Commission of England, studying the 
problem for four years, discovered that these people were increas- 
ing at twice the rate of the general population. It requires only 
a little thought on these facts to realize that we have before 
us not only a very serious problem but one which underlies 
many other social problems of the day. When we realize that 
a large percentage of our criminals, paupers, prostitutes, drunk- 
ards and ne'er-do-wells are mentally defective, we can but ask 
ourselves the question: What can be done to prevent all this? 

The attempt to answer this question has led to two proposi- 
tions: The first is to colonize them. Determine the fact of 
their defectiveness as early as possible and place them in colonies 
under the care and management of intelligent people who under- 
stand the problem; train them, make them happy, make them 
as useful as possible, but above all, bring them up with good 
habits and keep them from ever marrying or becoming parents. 
The other solution that has been offered has been to render 
them sexually sterile by surgical interference. 

These two methods each have their advocates and their op- 
ponents. As usual the solution to a problem so vast is not alto- 
gether simple and the methods proposed for the solution are not 
easy of application. 

Colonization appears to be the ideal method. Under the com- 
pulsory education law, all children now come to public attention 
when they enter school. Placed in colonies which are in reality 
well regulated communities where these people do all the work 
that they are capable of doing and live under conditions that 
are easy for them because simplified by the persons of intelligence 
who manage the colony, these children become happy and harm- 
less. A great many of them are trainable to do many things 
with their hands. They can carry on much of the work of the 
colony and become partially self-supporting or even completely 
self-supporting under direction. This is more than they could 
ever do if free in the world and besides they are thus kept from 



55 

propagating their kind — a result that cannot be attained if they 
are left in their native community. It is ideal and it looks easy. 
But we have only to consider a definite case to realize the difficulty. 

Our 15,000 feeble-minded children ir the public schools of 
New York City would require from eighty to thirty institutions, 
depending upon the number placed in each. The custom in 
many states is to have large institutions of from a thousand 
to two thousand inmates. With the larger number we would 
require eight such colonies for New York City alone. Many 
people believe that five hundred is enough for any one superin- 
tendent to have charge of. At this rate, we should require thirty 
institutions or colonies. New York City now has one. The 
whole state of New York has four. None of these has sufficient 
money or equipment and it is with great difficulty that they can 
be maintained even as they are, the public being unwilling to 
raise sufficient money to carry them on as they should be. We 
feel then at once the difficulty of providing enough of these colonies 
to take care of all the defective children. As is often true, 
however, the difficulty is not really as great as it appears. It 
would only be necessary to show as it sometime will be shown 
and appreciated by the people that the increased cost will be 
largely offset by the saving. We are not only planning for the 
future of these children, but the moment we begin to care for 
them, we shall reduce our expense for courts and prisons and 
almshouses, save the social losses that come from fires and injuries 
committed by these people, the moral injuries that come from 
their example and the prevalence of so much crime committed 
by them. Nevertheless it will take time to make this clear to 
all of our people. 

But this is not the greatest difficulty that we have to face 
in this matter of attempting to colonize all of the mental defec- 
tives. A greater difficulty lies in getting these children into the 
colonies. The majority, indeed, the dangerous part of them are 
not idiots technically so-called, that is to say they are not of so 
low intelligence that every one, the parents included, is convinced 
of their defect and is willing to have them placed in separate 
colonies. On the contrary, many of them are what are known 



56 

technically as morons or very high-grade defectives, who often- 
times do not show to the satisfaction of the parents that they 
are defective until they are adults in years and attempt to take 
their places in the world. The consequence of this is that the 
parents are altogether unwilling to have their children placed 
in these colonies. 

This comes from two causes: First, because of their parental 
love for their children, they are unwilling to send them away from 
home. Secondly, many of them are trainable to do errands and 
simple work which brings in a few pennies to the family treasury 
and this in many of these families is an important item. Until 
we come to the point where society is driven to the extreme of 
making laws requiring the forcible taking away of these children 
from their homes and placing them in the colonies, this matter 
will be an insurmountable difficulty. Many even of those who 
are allowed to go to the institution when they are young, where 
they become trained to a certain amount of useful work, are then 
taken home by their parents because that very training becomes 
an asset. So that at present, we are not able to keep in the insti- 
tutions even those that we get there. So much for the coloniza- 
tion plan. 

The advocates of sterilization, on the other hand, claim that 
they have a simple, safe and easy solution to the problem. They 
say to us that barring the danger of procreation, this element 
in the community will be no worse, or not greatly worse, in the 
coming generation than they have been in the past and while 
we will suffer some consequences of their condition, we can endure 
it for another generation if we are reasonably certain that it will 
then largely cease. Therefore, it becomes only necessary to render 
these people sexually sterile to solve the problem. 

It is easy to point to a feeble-minded man that lived six gen- 
erations ago who has become the ancestor of one hundred and 
forty-three known defectives and say "had he been sterilized 
this would have all been saved." 

Again, the plan is easy and appeals to us as reasonable and 
conclusive but the practical application of it is fraught with 
difficulty. In the first place, for its wholesale application, the 



57 

plan would involve going into the homes, declaring that such 
and such children are feeble-minded and liable to reproduce 
their condition and therefore must be sterilized. Up to date 
it has been very difficult to persuade the people of eight states to 
pass laws authorizing the sterilization of a limited number of 
assuredly incurable cases in a few institutions. How long it 
will take for us to get to the point where we will legalize the pro- 
cess of going into the families and sterilizing such of their members 
as may be declared feeble-minded, the reader is left to guess for 
himself. Before such laws will ever be passed, a vast amount 
of work must be done and many subsidiary problems solved. 
For example, we must discover some method of accurately 
determining what children are mentally defective. No one is 
willing to authorize the sterilization of a child as long as there 
is the possibility that he may turn out normal. That means 
that a large number of those who are really most dangerous to 
society would escape on the basis of the existent doubt. Secondly, 
we must be assured that in proceeding to apply this remedy, 
we are not jumping out of the frying pan into the fire, that in 
thus providing by our surgical interference that these people 
shall not propagate their kind, we are not putting into the com- 
munity people who will be a social and moral menace, much 
more serious to us than their actual feeble-mindedness. In other 
words, what will be the effect upon the social evil, and upon the 
spread of venereal disease of thus having in practically every 
community, some persons who are known to be free from the 
liability of having children? Will the relief from this fear lead 
lewd women, and men, of normal mentality to seek out these 
people with whom they can satisfy their passions without fear 
of consequences and in so doing, spread disease and debauchery 
broadcast? 

In the writer's opinion, this danger is largely overestimated, 
but this is only an opinion and we must have facts. The danger 
from disease could be largely if not entirely overcome by proper 
and efficient medical inspection. The increase of sexual immoral- 
ity would probably not be great since it is the testimony of most 
social workers and people familiar with this class of society that 
the fear of children is not a great deterrent. 



58 

We have been considering the wide and general application 
of this measure to all mental defectives who can be found, but, 
as has been said, the course that the matter is taking now, is 
to allow this operation to be performed on certain selected cases 
in certain specified institutions. Let us see the possibilities of 
this. In the first place, the operation which is generally proposed, 
of vasectomy, seems to have no bad effect physically or mentally; 
indeed, good effects are claimed for it. 

A careful study of this whole matter is being made by a Com- 
mittee of the American Breeders' Association and we shall doubt- 
less have some valuable facts on this matter in the near future. 

Practically the matter seems to stand as follows: Of the 
eight states having the law, only one has ever applied it; and 
even in that one case, the operation is at present abandoned at 
the suggestion of the governor on the ground that it is probably 
unconstitutional. The strongest argument against the consti- 
tutionality of the law is that it is a "cruel and unusual punish- 
ment." The idea of punishment comes into the question because 
the laws include among other persons who may be operated upon, 
the inmates of our jails, prisons and reformatories, that is to say, 
such of them as are considered incurably criminal. In the writer's 
opinion, it is a serious mistake that the question of criminality 
is brought into the matter at all. There is no agreement among 
criminologists that criminality is hereditary. Indeed, that 
theory is fast losing ground. Criminality is not born, it is made. 
The easiest material out of which to make criminals is feeble- 
mindedness. Therefore, if we could make our law apply to the 
feeble-minded and say nothing about the criminal, we would get, 
under that head, probably all of the criminals that need to be 
considered; and furthermore, if the term criminal could be left 
out of the laws, the idea of the operation being a punishment 
would entirely disappear. 

Returning then to those institutions and those cases where 
the laws can properly be applied, we have the following situation. 
If the individuals that are selected for the operation are never 
to go out into the world, the operation will be of no very great 
benefit to society. It will remove a little of the necessary pre- 



59 

caution in the institutions. That is of doubtful advantage. 
But it is true that many institutions for the feeble-minded have 
inmates who could go to their homes and be well cared for, their 
lack of ability to earn a living would be made up by others in 
the family and the state would be relieved of the burden. If 
they were safe from the danger of procreation, this would be 
a proper procedure. It is also true that our institutions for the 
insane are so crowded that many cases that are known to be 
chronic and incurable and are clearly hereditary, are often allowed 
to go home during their periods of quietness and while away from 
the institution, they become parents of children who inherit 
their weakness. If the operation were applied to these people, 
it would save a large percentage of defective inheritance. In 
the institutions for the feeble-minded, if these people above 
alluded to could be sent home, others could take their places, 
could be trained to work, sterilized and again sent to their homes 
to be fairly comfortable in those homes. In this way, in the course 
of time, considerable help could be offered to the solution of this 
problem and the burden of caring for so many people for their 
entire lives in colonies would be, to a certain extent, reduced. 

We thus see that in the present status of the problem, neither 
one of these plans will solve it at once, but since both are good 
and both can contribute somewhat to the solution, the only logical 
conclusion is that we must use both methods to the fullest extent 
possible. As we have attempted briefly to show, and as any one 
can discover for himself if he will give a little time to investigating 
the conditions, the situation is fast becoming intolerable and we 
must seize upon every method that is suggested and offers any 
probability of helping in the solution of the problem. In other 
words, it is not a question of segregation or sterilization, but 
segregation and sterilization. 

DISCUSSION. 

Dr. Alexander Marcy, Jr., Riverton, N. J.: 

Those of us who are familiar with the careful and painstaking work of Dr. 
Goddard will be willing to accept his conclusions as final, and personally I 
am inclined to agree with all that he has said. The question of how best to 



6o 

deal with this great problem of the defective classes, is almost unanswerable. 
From the data obtained as a result of careful investigations made by Dr. 
Goddard, Prof. Johnston and others, we are convinced of the certainty 
of the transmission of mental defects from parent to child and the greater 
the defect in the parent, the greater the deficiency in the offspring. This 
is true when one parent is a defective and more certainly true when both 
parents deviate at all from the normal. This being so positively certain, 
it only remains for us to consider how we can best deal with such cases, and 
how we can hope to overcome conditions which, if allowed to go on unchecked, 
must eventually overwhelm society. 

The question as to what we must do is comparatively simple but how it 
can be done is much more complex. 

We must prevent procreation, or the reproduction of their kind, but how 
we can best accomplish this is what confounds us. Sterilization is all very 
well, and if it were possible to sterilize effectively every defective, this solu- 
tion would be easy, but this is quite impractical for many reasons. 

There are many who disapprove of such a procedure on moral grounds, 
believing that we have no right to deprive an individual of a natural and 
God-given power for such a purpose. 

They forget that when God made man and breathed into him the breath of 
life, He made him perfect, in His own image, and that this poor, miserable 
apology for a human being is a result of man's own transgressions, and that 
his Creator cannot look with favor on any such travesty of His handiwork. 
He undoubtedly looks upon him with pity, but He surely cannot regard His 
reproduction with anything but disapproval. 

There are others who oppose it on legal grounds, claiming that the Con- 
stitution of our various states, as well as of the United States, does not grant 
the right by which we can exercise any such power, and therefore all acts 
which provide for the sterilization of certain defectives or criminals are un- 
constitutional . 

Whether this is true or not, we do not know, but it will be determined very 
shortly by the courts of last resort in some of our states, notably in New 
Jersey. Our law was passed about a year ago and up to the present time no 
operations have been performed under it. 

Our institutions are full of subjects suitable for such an operation but 
owing to the uncertainty of a legal right to perform them we have concluded 
to ask our Court of Errors and Appeals to decide the question. 

There are certain classes of cases that must be sterilized. The sexual 
perverts, masturbators, etc., and a certain class of criminals should be, e. g., 
rapists, and dangerous and incorrigible imbeciles. There are many of these 
in our correctional and reformatory institutions and they are hard cases to 
control. Dr. Sharp has observed in mauy of the cases operated on by him 
a wonderful change in behavior after both vasectomy and castration, the 
subjects becoming more docile and being much easier to control. In such 



6i 

cases however the question of our right to perform these operations is more 
likely to be called in question, as it partakes of a correctional measure, or by 
some might be considered a cruel and unusual punishment. Moreover in 
case of criminals it might be construed as an additional punishment, and 
therefore illegal unless the court at the time of sentencing the prisoner should 
include this as a part of the sentence. 

Surely in these cases in order that the punishment might fit the crime 
castration should be a necessary part of the sentence. The question of 
segregation may be unobjectional from a legal standpoint, but there are many 
other sides to this proposition. 

The greatest objection perhaps would be the financial one. To segregate 
properly and effectively all defectives would impose a burden on the tax- 
payer that would be almost, if not quite unbearable, and yet, as Dr. Goddard 
has pointed out, it might be economy on the part of our communities in the 
end to issue bonds to build and equip enough institutions to care for all de- 
fectives, as by so doing, in a few generations, this class of dependents would 
practically be eliminated, that is in so far as the hereditary transmission of 
defect goes. 

Aside from the financial burden, it would be a difficult matter to get all 
defectives into such institutions, and whether or not it is within the province 
of the state to pass compulsory laws that would cover this phase of the 
question, I do not know. 

What would be the standard of mentality that would decide who should 
be put in such an institution and how would it be determined? 

These are all grave problems and are not easy of solution, but the fact 
remains that something must be done, some concerted action must be under- 
taken to relieve society of the rapidly increasing burden of our defective 
classes, and I believe Dr. Goddard is entirely right when he says that it is not 
a question of sterilization or segregation, but one of sterilization and segrega- 
tion. 

Proper and efficient marriage license laws which will prohibit the unfit 
and the unhealthy from marrying will help in the solution and it is to be hoped 
that every state will soon have a uniform and comprehensive statute that will 
effectively deal with the problem from this view point. 

Dr. H. M. Carey, Spring City, Pa. : 

I am thoroughly convinced that something must be done to overcome this 
great problem staring us in the face. Segregation is all right if carried out 
in detail, but to be effective the law must be mandator)'. It must enable us 
to get every single case of deficiency, feeble-mindedness and epilepsy into the 
proper institution and under the proper custodial care. If we are going to 
eliminate this scourge, as it has been called, it must be done thoroughly. 
A law was introduced in one of the western states which, I think, dealt very 
conclusively with the subject. Unfortunately it was about fifty years be- 



62 

fore its time. This law distinctly stated that every single case of mental 
deficiency must be reported, just as the law requires small-pox to be reported. 
The person was admitted to an institution for examination. At the end of 
six months the medical authorities of the institution reported as to the con- 
dition of the case — whether recovery was probable, whether special training 
was needed. Then it was the object of the law to have that case committed 
to the institution for life with this understanding: That if the parent of the 
child wished to remove the child from the institution it could be done only 
after an operation which would prevent procreation. This was meant to 
overcome the objections to both sides. The individual for whom operation 
was not desired, had the opportunity of segregation. If segregation was not 
desirable, there was opportunity to have done the operation which would 
allow him to be taken home. As I have said the law was fifty years before 
its time. There is hope, however, that other states will take up the same 
question. I understand that we are about to have a bureau dealing with this 
subject, and it may be possible to take up this problem at headquarters. 
State Legislatures and the National Government should be shown that some- 
thing must be done. The court has very little authority to commit an 
individual unless crime has been done. We have cases come to us in which 
the parties should not be allowed to be free, yet in every case, upon the de- 
mand of the parents, they must be released, and they are turned out as a 
menace to the community. It behooves us all to do our best to bring about 
correcting influences. 

Dr. Jane K. Baker, West Chester: 

My experience in the last ten years in the almshouse in which I worked 
has given me a great interest in this subject. We had admitted 1 10 women 
to the maternity ward. The population from which these women came 
numbered 96,000. 105 of these women, one might justly say girls, were 
feeble-minded and deserted. That such a condition could exist in a com- 
munity largely rural shows plainly the great necessity for a more protective 
care of the feeble-minded girls. 

Dr. W. S. Cornell, Philadelphia: 

I feel that the major part of the work should come from those who have 
charge of these cases and can speak regarding hundreds of cases. Dr. Carey 
speaks from that standpoint. One case which has been cited before is illus- 
trative of many in these institutions: A girl who was an attendant at an 
institution for the feeble-minded resigned her position to marry one of the 
ex-inmates, a high-grade defective. Later two feeble-minded children were 
born to these two. This case might be duplicated in many institutions. 



VII. 

CHILD LABOR VS. THE CONSERVATION OF SCHOOL 

CHILDREN. 1 

By Owen R. Lovejoy, New York, General Secretary of the National Child Labor Committee. 

The subject of this Conference is the largest single topic that 
can engage the attention of the American citizen. You have 
been turning your attention toward various phases of the problem 
of the conservation of school children, especially from the points 
of view of the educator and the physician. I am invited to dis- 
cuss the conservation of school children as affected by the problem 
of child labor. 

Without laying any claim to familiarity with the details of 
the technical problems that have engaged you in these discussions 
— the problems of education which our teachers and schools 
are working out, and those problems of the health of children 
with which physicians are familar — it may be possible to add 
one or two suggestions from the point of view of those who come 
in contact with the problems of the education and health of chil- 
dren in studying the causes, conditions and effects of their em- 
ployment. 

The relation of child labor to education has not received the 
attention it deserves either by those engaged in child labor re- 
form or by those engaged in educational work. It has not been 
made sufficiently clear that the two cannot thrive together, or 
that the one part of the problem cannot be solved without states- 
manlike treatment of the other. The close relationship is indi- 
cated by the fact that in states which provide a minimum age 
limit for the employment of children it is a matter of record 
that the majority of children leave school and enter employment 
within a few weeks of the birthday set by law. In states which 
provide no age limit, but leave the matter of child employment 
practically neglected, children leave school at a much earlier 
age, and the percentage of illiteracy is strikingly higher. 

In dimensions, the problem of child labor stands between 

1 An address at the Conference on the Conservation of School Children, Lehigh Uni- 
versity, April 3, 1912. 



6 4 

those specific numerical facts familiar to the school men and 
those familiar to the physicians or hospital specialists. There 
are not, on the one hand, so many children engaged in gainful 
occupations as are in school. On the other hand, many more 
children are employed in various occupations than ever appear 
for special treatment in orphanages, sanitoria, or hospitals. 

The census returns of 1900 show approximately 1,750,000 
working children between 10 and 15 years of age. What is still 
more significant, the same report showed that during the 20 
years preceding 1900, while the population of the country had 
increased approximately 50 per cent., the number of working 
children had increased approximately 150 per cent. It further 
showed that the branches of the army of child workers had 
increased most rapidly in the kinds of emplo)nnent that offer 
the least opportunity for physical and mental development, 
and give the least promise of training for industrial efficiency. 

There are no complete census statistics since 1900. For 
twelve years our country has been compelled to depend on these 
figures, which were very inadequate and unsatisfactory even 
when they were issued, and are of still less value at the present 
time. It may be that the census returns on child labor gathered 
two years ago for the 13th census will not be published at all. 

To indicate the unsatisfactory nature of the 1900 report, 
I may point to two concrete illustrations. The census showed 
668 newsboys and newspaper sellers for the entire United States. 
While we know that in each of the large cities like New York, 
Chicago, Philadelphia and Boston, there are several times this 
number, and countless thousands scattered through the smaller 
cities and villages of the country, we must agree that the total 
returns published in the census are somewhat affected by such 
an item as this. Furthermore, the report contained no mention 
of children under 10 years of age, yet in New York, to a great 
degree, and in other cities where tenement home work is done 
to a lesser degree, we know that hundreds of little children from 
5 to 10 years of age work several hours a day and often far into 
the night manufacturing goods for commerce. 

A system which takes - out of the public schools at least two 



65 

million of its children under 16 years of age, draws them away 
from school before more than a small percentage of them have 
learned anything that will be of permanent educational value, 
is a system deserving the most careful attention of the educator, 
even if he be interested in nothing beyond his profession. 

Also, a system which according to the meager reports issued 
by the various state labor departments shows uniformly a higher 
ratio of disease and accident than is shown in the case of adults 
employed side by side with these children, is a matter of definite 
concern to physicians and other guardians of public health. 
For the present, therefore, laying aside any discussion of the 
economic advantage or disadvantage of child labor, passing over 
the relation of such employment to the moral development of 
children, we have before us a matter for definite action which 
in our judgment can best be handled by the combined efforts 
of those who guard the public health, those who foster education, 
and those specifically engaged in the more disagreeable task 
of reducing the immediate abuses of child labor through adequate 
laws efficiently enforced. 

Child labor exists in America because three parties want it 
— the employer, the parent, and the child. Since these are the 
only three parties directly interested, they constitute a combina- 
tion hard to break. Of course, not all employers nor all parents 
nor all children favor the system; but there are enough of each 
class to effect a good working force. The combination will 
never be broken unless by the combined efforts of those who see 
the implications of this problem and are able to interpret its 
significance to the general public. We have confidence then 
that the people of the country will not continue to tolerate what 
has already convinced many serious students as being a menace 
to education, health, and good citizenship. 

How can we combine our energies? Perhaps I can best sub- 
mit the question by stating briefly the natural limitations which 
the National Child Labor Committee seems to find to its proper 
field of action, as well as some of the positive efforts we put 
forth. 

When the National Child Labor Committee entered upon 



66 

its work seven years ago, it faced one large question which must 
be answered in determining its policy. Should it undertake to 
establish such evidence regarding every form of child labor as 
would convince every one to whom the evidence was submitted, 
or should it undertake to act on the basis of such information 
as was at hand or could be quickly gathered? There was much 
to be said on both sides. We might, on the one hand, become 
a body of expert scientists, preparing carefully analyzed reports 
to serve in ten or twenty-five years from now as conclusive evi- 
dence in relation to present problems. We might, on the other 
hand, undertake to direct public attention to some of the more 
glaring abuses of the system in the hope that these abuses might 
be speedily corrected, and that eminent scientific bodies would 
take up the more fundamental forms of research. 

For example, statisticians everywhere recognize a certain 
hazard in industry; and a body of legislation is being created to 
regulate the conditions under which people shall be employed. 
Students in universities, hospitals, and elsewhere are seeking 
to work out schemes by which a larger share of the burden which 
now falls so heavily upon the injured workman shall be trans- 
ferred to the state or to the industry itself. In looking upon 
this problem, we discover that the social responsibility, already 
fairly well recognized, applies especially to children. Not only 
are children less intelligent, less cautious, and less able to defend 
their rights, but their physical inferiority exposes them to dangers 
which do not threaten the adult. Reports from a few states 
indicate that injuries to children under 16 years of age are in a 
ratio strikingly higher than to adults in the same industries. 
These statistical reports are meager, and many sections of the 
country are entirely devoid of such information. 

However, it seemed to us that a committee formed to protect 
the interests of the working children should not wait until a 
complete body of statistics had been gathered, but should at 
once attempt to correct an abuse which confessedly threatens 
the safety of the young. We, therefore, decided to leave to 
statistical experts and medical scientists the more satisfying work 
of determining the exact per cent, of accidents to working children, 



6 7 

and set ourselves to the task of arousing public interest and se- 
curing legislation against this sacrifice. We assumed, and I 
believe are thoroughly scientific in so assuming, that children 
are an unsafe industrial risk. We assumed that the high per- 
centage of accidents to working children in certain industries 
was not a coincidence, but was intrinsic, and therefore that child 
labor in certain specific dangerous occupations might, without 
injury to society, be suspended, at least until some body of scien- 
tific experts could come forward and prove that these scattering 
figures are not indicative but purely incidental, and that the little 
child is safe in contact with exposed machinery. 

Complete statistics were not available to show the exact re- 
lation between child employment and compulsory school attend- 
ance ; but we believed the statistics already gathered were sufficient 
to indicate that there is a relationship. Therefore, without wait- 
ing for ten years to bring up every scrap of evidence that might 
be gathered we took the evidence that lay at hand, and began 
to use it for creating a better system in various states. 

Or suppose we consider the proper hours for employment of 
the working child. So far as we know there are no statistics 
gathered to show that it is more injurious to work all night 
than all day in glass factories. We have individual statements 
from a number of mothers to the effect that their children lose 
appetite when on the night shift; that they lose in weight; that 
their day sleep is fitful and broken. But this is evidence that 
a statistician would not consider conclusive. However, it seemed 
wise to the committee to rely on the common judgment of the 
race, that night is the time for sleep and day the proper time for 
work. We have, therefore, conducted campaigns in a number 
of states for the elimination of all children under 16 years from 
the night shift in glass factories. Where these laws have been 
in effect long enough to indicate a changed condition, we have 
abundant testimony from physicians, school teachers, and others, 
that school attendance increases, that the morals of the children 
in the towns are improved, and that general satisfaction prevails. 
We are, therefore, inclined to continue the campaign for the 
elimination of children from night work in glass factories, as 



68 

well as in other industries, until perchance it shall be proven by 
those qualified to make a thorough test of obscure physical 
indications, that we have made a mistake and that the physical 
welfare of children and of the race will be promoted by child labor 
at night. 

Our attitude toward the length of the working day has been 
the same. No scientific evidence has been produced in favor 
of an 8-hour day, as against a 10- or 12-hour day for working 
children; but the Federal Government has established the 8- 
hour day on all its contracts. A large percentage of states in 
the treatment of those receiving state care, whether in reforma- 
tories or penitentiaries, have limited their working day to 8 hours, 
on the ground that the physical standards of the institution are 
better maintained. The trades unions, wherever strong enough, 
have established the 8-hour day as the standard for stalwart 
men. Many manufacturers on their own initiative have estab- 
lished the same limitation in the belief that production will be 
stimulated; and that society in general will be benefitted. All 
this is not conclusive evidence, but it seems to us to constitute 
a working hypothesis, and we have proceeded on the assumption 
that a working day long enough for state and government em- 
ployees, long enough for penitentiary convicts, long enough 
for vigorous, adult men, is not too short a day for growing children. 

The other lines of activity to which I have alluded are, of 
course, not less important. Workers in all lines of social service 
in this country are seriously handicapped by lack of strictly 
scientific evidence on which to base their program. Those 
who are interested in the conservation of school children, whether 
from the educational or the physical point of view, could not 
render any greater service at the present juncture than by en- 
couraging such thorough and exhaustive research as shall at the 
end of a decade or quarter century leave no room for doubt 
in the public mind as to the extent, nature, and effects of the 
considerations we have here under discussion. 

School men can study this problem without greatly adding 
to their daily burdens. The operation of the truancy law, the 
needs of the exceptional backward child, the problem of the 



6 9 

repeater, the development of courses of study fitted to those who 
demand physical activity, all these and similar problems present 
to the teacher interested in child conservation an opportunity 
to render a social service of prime value not only to the children 
involved but to the community and the communities of the 
future. 

To the physician, hospital manager, or health officer, the prob- 
lem should be equally intimate. How seldom do hospital 
records show the industrial history of the child or youth or adult 
brought for treatment; and yet through a series of years an accu- 
mulation of evidence would be possible, the value of which is 
beyond our present belief. We were told a few years ago by 
students in Chicago that certain hospital cases analyzed as to 
their industrial history gave evidence that they were simply 
worn-out human machines at 40 or 45 years of age, as the result 
of early hard work. To what extent is this true? Revelations 
that are coming to the public of phosphorus poisoning indicate 
how defective are some physicians' reports and hospital records. 

In the case of children, there should be an effort, not to make 
the record as brief and obscure as possible, but as full and re- 
vealing. 

I am confident that we must all take higher ground in relation 
to the care and training of our children than we have thus far 
taken in this country. We are developing our business to-day 
and regulating business on the newer theory that society has 
a right to dictate how its goods shall be produced and under 
what conditions they shall be handled. The business interests 
of manufacturers and merchants impel them to the development 
of higher specialized modes of securing efficiency. But when 
it comes to the human part of the problem, very little attention 
is given and very little is known. With an assumption that 
we are wearing very lightly, we assume that the majority of our 
children will pass through a normal and healthy childhood and 
youth and come safely to a well developed maturity. In the 
same way we assume that if a child is taken care of by our public 
schools for 4 or 5 hours a day, 5 days a week between the ages 
of 8 and 14 years, the child will be prepared for citizenship in 



70 

our democracy. Both assumptions are unwarranted, especially 
the latter. I venture to predict that the time is near at hand 
when in all our more advanced states we shall recognize that 
the child is so truly an asset of the state that during this entire 
period of its minority the state will claim supervision of its care, 
its physical training, and its educational opportunities. 

I do not mean to indicate that the relation of parent to child 
will be less than now. On the other hand, it will be more. The 
service rendered will be larger and finer and more significant. 
There will be more freedom; but at the same time less neglect. 
We shall begin seriously to banish ignorance by seriously under- 
taking to meet the needs of an industrial civilization with educa- 
tional processes fitted to the present appetite of parents and 
children, thus leading them on step by step from the mere con- 
sideration of the wage-earning value of education to the higher 
ground, the appreciation of its service in citizenship and the higher 
requirements of life. 

To accomplish this, we must all know more than we do to-day 
of industry. The health officer must become the strong arm 
of our city, state, and federal governments. To-day in many 
sections the health officer is the physician who could not succeed 
in private practice. The policeman is considered far more im- 
portant; but with the discovery of the causes of typhoid, tuber- 
culosis, diphtheria, and other scourges, with the discovery of the 
serious after-results of malnutrition in babyhood, the health 
officer is predestined to rise in the near future to so prominent 
a place that the community will look upon him as its chief servant. 
We must begin to insist that education and health are the para- 
mount assets of our civilization and that without these democracy 
cannot achieve its mission either in relation to other nations 
or to the more immediate demands of its own citizens. 

DISCUSSION. 

President Drinker: 

I think we can be happy from living in an age when such opportunities 
are presented in so sympathetic an atmosphere. I for one feel that the world 
is growing better. I think we all feel in regard to this question that it is 



7i 

one of those which when we discuss we find all the world beginning to think 
alike. 

Mr. Louis Nusbaum, Philadelphia: 

I, too, am an optimist by professional training and practice. From the 
point of view of one of those educators in sympathy with these ideas, and 
from the point of view of one who has come in close contact with this work 
and realizes the shortcomings of our school system, I can appreciate such 
cases as have been brought to our attention by Mr. Lovejoy. I think further, 
that we are making strides in the direction suggested by him. There is no 
doubt about the absolute right of everything he has told us and of our duty 
in this matter. But, for a number of years, from my work as the principal 
of a school in the heart of the slum district of a large city I can say that an 
intensive investigation of every case requiring charity among the patrons 
of the school would have kept a charitable organization busy for the best 
part of the year. The puzzling question is what to do in a case typical of 
hundreds. A mother of five or six children, the oldest of which is 13, comes to 
the school and states that she cannot let this oldest boy come to school be- 
cause the father is sick with tuberculosis, and they are living in one room, 
the rent of which is paid by some charitable organization. While we are all 
agreed as to the inherent rights of the growing generation to a decent start 
in life, we are honestly puzzled to know what to do in the case of the poor 
mother. Is it fair that we always shall let this generation suffer to improve 
the condition of the next? 

Dr. Groszmann, Plainfield, N. J. : 

The system of pensioning widows or disabled workmen is not at all a new 
proposition and it is established in various communities and states in Europe. 
It may be well to mention the laws of Germany in the matter of working- 
men's insurance. Out of the earnings of every workman a certain percentage 
is taken by the state to provide for sickness and death. We must remember 
that child labor is the result of economic conditions. There must be con- 
structive legislation as well as restrictive legislation. If we shall be able to 
introduce into our country some of the constructive legislation enacted on 
the other side we may obviate some of the difficulties presented. 

Dr. H. M. Bracken, St. Paul: 

I am glad to have heard Mr. Lovejoy refer to the close association of public 
health, child labor and education. These should go hand in hand. It is 
encouraging to have him put health before education, because education 
without health is of little value, and the child growing into adult life without 
health is of little value. Mr. Lovejoy referred to the unfortunate fact that 
our health officers were incompetent. This is not quite a fair statement. 
Most of our health officers are busy physicians whose first duty is to make a 



72 

living for their own families and they will neglect their duties as health 
officers rather than their duties to their children. This type of health officer 
should be done away with ; we should have men and women who would give 
their whole time to public health just as they do to educational problems. 

The speaker refers to the amount of money spent on education. In my 
own state from six to eight dollars per capita is spent on education and 
three cents per capita on public health. 

Dr. W. S. Cornell, Philadelphia: 

I believe we should take a firm stand on the statement that the child should 
be given a chance. Democracy means that every child should have an equal 
opportunity. I understand that the New York Society for Organizing 
Charity can take care of every case. There are private agencies to take care 
of unfortunate and deserving people. A lot of the boys get into bad company 
in addition to lacking education. We shall never solve the problem until 
we have compulsory registration of births. 

President Drinker: 

While not experienced in this line of work, but speaking as one who left 
Lehigh forty-two years ago, and went up into one of the mining regions where 
the children spent much time in hard labor, I am in a position to heartily 
appreciate Mr. Lovejoy's remarks concerning child-labor, and of the laws in 
force in some of the western states. In regard to the question of help from 
the corporation in case of disability of the employee, the western states are 
far ahead of anything we have here. 

Mr. Lovejoy: 

I am glad the speaker brought out the comparison between education and 
health. That ought to be known all through the country. Alcohol is a 
large cause of child labor. One of the most stubborn sections of the country 
for child labor was where they do not have alcohol, and the people are mostly 
Methodists and Quakers. While the saloon and child labor do not always 
go hand in hand, in many instances women are left helpless and poor through 
the ravages of that curse. 



VIII. 

TEACHING HYGIENE IN PUBLIC SCHOOLS: WHAT 
SHOULD BE TAUGHT? THE PHYSICIAN'S VIEW. 1 

By Seneca Egbert, A.M., M.D., Philadelphia, Professor of Hygiene, Medico-Chirurgical 

College. 

To consider in full the teaching of hygiene from the stand- 
point of a physician would involve a scope of the theme so broad 
as to demand much more time than is alloted to me this morning. 
In fact, this great science to-day relates or is related to almost 
everything that affects the physical life of man, and is also con- 
cerned with many of the experiences of his mental and spiritual 
life. 

Happily, public opinion is at last coming to appreciate that 
hygiene should hold, above almost everything else, a leading- 
position in the school curriculum, and that its fundamental 
principles, at least, should be instilled into every pupil old enough 
to comprehend them and appreciate their importance to his 
or her future welfare. For too long a time our people have 
been accustomed to worship mental education almost as a fetich, 
and have failed to see that minds developed at the expense of 
physical soundness are as houses builded upon sand. But such 
states of opinion are passing and we are beginning to realize 
that in the conservation of our national resources there are 
none of more value or importance than those represented by 
the human vitality and physical health of our citizens. And so 
we are moved at last to endeavor not only to secure for our 
children sound bodies as the abodes for sane and well developed 
minds, but also to teach them in our public schools those things 
which will enable them to conserve and improve their physical 
health throughout their natural lives. 

Wherefore, we may well consider what shall be taught. 

Speaking as a physician, it seems to me that we should first 

1 Read at the Conference on the Conservation of School Children, Lehigh University, 
April 4, 1912. 



74 

have them know and appreciate their bodies as vital entities 
and especially as of a triune nature. In other words, that no 
one may reasonably hope for excellence in living if either the 
spiritual, mental or physical personality and its needs be neglected , 
and that the wise and efficient man must strive to develop all 
three parts of himself. This involves, of course, a practical 
working knowledge of human anatomy and physiology, not 
as complete, it is true, as the intelligent individual will for his 
own advantage acquire later, but fairly comprehensive and sound 
in principles, so that future knowledge will not be warped or 
colored by faulty notions or misconceptions. Need I say that 
this necessitates teachers competent to give such instruction 
who have a real enthusiasm for the subject, and also suggests 
the omission of unessential and, for the time, useless details. 
There can be no excuse for anatomy and physiology, jointly con- 
sidered as they should be, seeming a dry or uninteresting subject 
to any child, and, least of all, for any professed teacher admitting 
that it may be. 

In such efficient and fundamental teaching of the body's 
structure and function there will naturally be many opportunities 
for expressing and emphasizing laws and rules of personal hygiene 
and for creating a positive desire for that sound condition of 
body indicated by continued good health and high physical, 
mental and moral efficiency. 

This preliminary instruction leads to the study of disease and 
its classification and causes, that it may be avoided, prevented 
or cured. The most elementary classification of disease at once 
indicates that many of the ills that flesh is heir to or afflicted 
with are due to an abnormal condition of the patient's own 
body — faults of nutrition or excretion, for example — and, on 
the other hand, that a considerable number of maladies are the 
result of the invasion of the body by living microorganisms from 
without. This opens up broad lines of study with respect to 
one's environment and concerning modes of infection, immunity, 
prophylaxis, etc. 

How a well-informed teacher could fail to make our present 



75 

knowledge pertaining to the causes and transmission of the in- 
fectious diseases and to the means of prevention most interesting 
to even young pupils, I fail to see, and still more attractive to 
all must be the investigation and study of our modern achieve- 
ments in the development of immunity to such maladies. More- 
over, the appreciation of the reasons and necessity for such 
protective governmental measures as quarantine, disinfection, 
compulsory vaccination, etc., makes for good citizenship in more 
than one respect, as we shall see later on. 

As for the relation of environment to health and disease, we 
here enter upon a field of study that may be limited only by 
the time that may fairly be apportioned to our general subject. 
All such questions as involve the atmosphere, water, food, and 
their respective impurities, our habitations, clothing, exercise, 
heredity, habits of living, sex and social relations, the disposal 
of wastes, etc., can be taken up in turn and studied with profit. 
Nor should opportunity be lost of including in the course special 
instruction regarding sex hygiene and the influence of heredity, 
without which no study of general hygiene may be considered 
at all complete. 

Granting that some such comprehensive instruction in the 
subject should be given to every boy or girl before leaving the 
public schools, one result will almost surely develop: the pupil 
who at first was simply interested and curious, will soon strive to 
learn for the sake of his personal benefit and self-improvement, 
and then, before he is really aware of it, will become altruistic 
in his motives where hitherto he was rather selfish or egoistic. 
This is one of the peculiarities of the study of hygiene. Whoever 
pursues it, even though to a limited extent, not only gains that 
which will benefit him physically, but becomes a better and 
higher social being, moved with a desire to help others than 
himself. 

A question that naturally arises is as to when such teaching 
should be imparted. Instruction of very young children in 
matters hygenic cannot be very systematic or thorough and may 
possibly be best done, if at all, by attempting to inculcate com- 



7 6 

paratively few and simple truths and by directing attention to 
good examples for practice and imitation. It is doubtful whether 
a pupil in the primary grades can appreciate much of anatomy or 
physiology except that which concerns the exterior of the body 
or the simpler structures and functions; but we may at this time 
make a beginning of the nature studies that will later on lead 
gradually and almost unconsciously into the proper apprehension 
of sex hygiene as one important phase of the general subject. 

In fact, were it not that by far the greater number of public 
school pupils nominally terminate their education in the grammar 
schools, it might be well to postpone much of the systematic 
teaching of hygiene and sanitation until after admission to the 
high school. It is, however, a matter of great practical impor- 
tance that almost thirty per cent, of our total population is under 
fourteen years of age and that most of those that survive will 
leave school forever at that period or within a year or two there- 
after. We must accordingly do what we can to give these such 
instruction as will help and protect them in after-life, and so a 
well arranged course in hygiene, including some discussion of 
as many of the foregoing subdivisions as the scholars can reason- 
ably comprehend and assimilate, should be made a part of the 
schedule for the grammar school. 

Such a course, in order to awaken lively interest and fix im- 
portant fundamentals as principles of conduct for the after-life, 
should appeal strongly to the pupil's personal consciousness and 
sense of self-profit in the higher sense. If we can give the boys 
and girls of these grades a fair working knowledge of their body 
structure and functions, of the nature and causes of disease and 
means for its prevention, of the reasons and necessity for govern- 
mental rules and regulations concerning transmissible maladies, 
and such appreciation of the laws that govern the maintenance 
and improvement of health, not forgetting honest and reasonable 
instruction in the principles of sex hygiene, we shall be doing much 
for our future citizenship and the public welfare. 

For those who are fortunate enough to advance to the high 
school, I would use the foregoing as a basis, expanding and 



77 

enlarging upon the respective themes already mentioned, until 
the course involved an extensive scope of the general subject 
and, as intimated, until the altruistic appreciation of it supplanted 
the egoistic and it was actually apprehended as being, in truth, 
the Science of Public Health. 

There is no reason, so far as I can see, why every high school 
graduate should not and may not have a right knowledge of his 
or her own body, should not look upon health as the greatest 
personal asset next to moral character, should not appreciate 
it as most valuable capital in entering upon one's life-work, 
and should not also comprehend one's duties and one's oppor- 
tunities in helping and uplifting others. Nothing in the scope 
of general hygiene and sanitation should be beyond the ken and 
comprehension of an advanced high school pupil. It is essentially 
a common sense study, with enough of scientific discovery and 
achievement to not only awaken a lively interest but also to 
furnish a substantial basis for a plan of action and self-control. 
A knowledge of the true nature and etiologic agencies of disease 
must prevent any one from being deluded by false doctrines of 
life or worshiping false gods of therapy. 

So also, an appreciation of the human body's power of self- 
protection and of the principles of immunity that are now being 
so wonderfully revealed by the investigations of many earnest 
workers in this domain, must prevent a nihilistic attitude regard- 
ing disease and lessen opposition to those measures that are rapidly 
eliminating one scourge after another from human experience. 
When the high school boy sees that within the short period of 
his life, yes, even of his school life, diphtheria, malaria, yellow 
fever, typhoid fever and other equally grave maladies have been 
conquered and have lost their power to terrify, and when he also 
sees that this has been done by means and methods entirely 
within his comprehension, he is not likely to be an obstructor 
of progress, but a good citizen who will enthusiastically support 
the health laws and administration of his city, state and country. 
He will comprehend, as France has already done, that Pasteur 
and not Napoleon was the greatest man of his nation; when the 



73 

Panama Canal is opened for traffic, he will first give credit, not 
to the engineers who constructed it, but to the able physician and 
sanitarian who went before and made the work possible, and he 
will look upon the saving of 25,000 lives in Pennsylvania within 
the past five years as a far greater and nobler achievement than the 
founding of a pseudo-science and the acquisition by a Mrs. Eddy 
of many paltry dollars and an ephemeral fame. 

From the standpoint of the physician, there is, indeed, much 
of hygiene that may well be taught in our public schools: much 
that is already available for teaching. What is really needed 
for the work are competent teachers. Where shall we find them? 



IX. 

TEACHING HYGIENE: WHAT SHOULD BE TAUGHT? 
FROM THE TEACHER'S VIEWPOINT. 1 

By Percy Hughes, A.M., Ph.D., South Bethlehem, Pa., Professor of Philosophy and 
Education, Lehigh University. 

In the development of school hygiene, the medical and teaching 
professions are working in very close association. Not only have 
the chief medical societies made school hygiene a subject of 
investigation, but, in the National Education Association, physi- 
cians have taken a leading part in the work of the departments 
of School Hygiene, Physical Education and School Patrons. 
The American School Hygiene Association is composed largely 
of physicians, many of whom, representing departments of physical 
education in colleges, schools and school systems, are supervis- 
ing every feature of school life, in its hygienic aspect. Some 
of our best text-books in hygiene are prepared by physicians 
experienced in teaching. The medical inspection of schools 
must result in still closer association between these two profes- 
sions, and will undoubtedly affect most favorably the attitude 
of the individual teacher towards the teaching of health. 

Therefore the physician is prepared to recognize that the social, 
scientific and economic demands for a greater emphasis upon 
education for health combine with a similar impulse that has 
arisen within the school itself. Health, in the broad sense, is 
the direction in which all educational reforms have been working, 
and in modern education this impulse has been greatly accentu- 
ated by the systematic study of child nature and by investiga- 
tion into the causes of retardation in schools. 

In many of our more important schools and in our large school 
systems, radical revisions are now being made in the teaching 
of hygiene. These changes, then, are a natural growth of educa- 
tional theory and of school life. 

In studying these revisions I believe we notice certain tendencies 
or directions as to what shall be taught in school hygiene. As 

1 Read at the Conference on the Conservation of School Children, Lehigh University,, 
April 4, 1912. 



8o 

I am to discuss this question from the teacher's standpoint 
I shall not so much attempt to indicate what topics in hygiene 
should be studied, as to state what phases or aspects of each 
and every topic the teacher, as I see him, tends now to select 
for emphasis and as the center of instruction in hygiene. 

Many of our text-books in hygiene still contain much physio- 
logic information, the application of which must come, if at all, 
much later in life. And even the best text-books discuss matters 
in a way that has little force to the child. These characteristics 
seem largely to be the result of a wave of reforming enthusiasm 
which some twenty-five years ago led our schools to center in- 
struction in health upon physiology. 

But experience has shown that information has little effect 
upon the child unless he can apply it to his child life, and it is 
sometimes injurious to ask him to take the adult point of view. 
Indeed, it seems that health is not an interesting subject to the 
child, and there is some danger of morbid effects, if through 
eight years we center the child's attention upon his body. 

Hence, it appears to be the present tendency to center hygienic 
instruction not upon physiology, but upon the training of the 
child in habits which fit him to live efficiently and happily his 
present child life. Our general system of education, which 
compels a group of children to study words for hours seated 
in a confined atmosphere, of itself raises hygienic problems in- 
numerable which we endeavor to solve in the presence of the child 
and with his aid. By centering his attention upon the problems 
of school life around him, we maintain in him the objective 
attitude. Thus what we shall teach is not so much information 
for future use as habits for present efficiency and happiness; 
for it is held that we best prepare the child to live well later on 
by teaching him to live well now, as a child. This is the first 
tendency I would note in present revisions. And the second 
is like it. 

The school now attempts to unify the whole school life of the 
child in terms of health. Here the teacher is compelled to insist 
that we can not separate the health of the body from that of 
the mind, not only because one often is the cause of the other, 



8i 

but, even more, because the health of the body does not mean 
keeping free from sickness and living long ; it is wholly defined 
and measured by the health of the mind whose servant it is; 
also that, to make the conditions of a school healthful, the teacher 
considers not only such matters as medical inspection, physical 
exercises, domestic science and art, but also such studies as history, 
geography and literature, and the social as well as the physical 
atmosphere of the school room, with the intention of cherishing 
a broad interest in the world's life and work, a hopeful outlook 
upon life, and a disposition to cooperate in achievement. We 
may symbolize this unifying tendency by saying that we would 
have our schools temples of health rather than of learning. 

So the period which according to law we devote to hygiene 
we tend to regard as a time for reflection upon the training for 
the whole school life of the child, at the time. We find it difficult 
to distinguish moral from hygienic problems, or to separate 
the physiologic from the psychical conditions of health. 

There are some very eminent in the teaching of hygiene, who 
feel that no period should be given to explicit instruction in health 
or hygiene. They carry to an extreme, as I understand it, 
the idea that his own health is not a natural interest of the child, 
and that it nurses morbidity of disposition to dwell upon health 
as an end in itself. 

But it seems a sound principle that whatever we wish the 
child to recall and use intelligently we should bring explicitly 
to the focus of his attention, and there is good reason to believe 
that the principles of conduct and health will gain in force and 
applicability if they are brought together in systematic and organ- 
izing instruction at some definite period devoted to that work. 

The objections to this explicit instruction in hygiene are met, 
I believe, by the contention that it is not health in the narrow 
sense that we are teaching. We are making clear to the child 
the means whereby the school life is maintained on a plane of 
happiness and efficiency in achievement. Of course, the first 
point is that it be so maintained, for only by living the healthy 
life can the child understand why he should live it. The in- 
formation we give will be forgotten, or will not be applied; the 



82 

habits in which we would train him will in times of stress be 
broken, and will not be renewed, unless the child actually expe- 
riences the joy of living in physical and social health. Without 
that insight, memory, and ideal, we instruct and train in vain, 
for the motive is lacking to apply. 

I will endeavor to give these words some concrete meaning by 
mentioning some things which are thus taught during the period 
devoted to hygiene. Since it is reasonably safe only to assume 
that a child will stay in the school until he reach the fifth grade, 
we may take the work of the first five grades as a unit, in which 
the indispensable is taught, and call elementary hygiene. 

Our better primary schools and kindergartens approach during 
the first two years of school life the method now made famous 
by Dr. Montessori, in teaching little children hygiene. The 
child is taught self-help and deportment, learning, so far as 
possible, to wash and dress itself in just the right way, to meet 
people and leave them, to speak and listen and move about on 
all occasions with grace and precision. In the spirit of play the 
children may thus attain great efficiency and self-control, and 
the attitude is objective, directed towards the life of the school 
room, and the dolls, the flowers and the animal pets which the 
school room should house. Physiology is here taught only in 
so far as it is useful in learning these activities. 

Without descending too far into detail, I may illustrate what 
should be taught in the third and fourth grades, by the "Daily 
Routine," which each child may draw up for himself under the 
suggestions of the teacher, and which may take the following 
form, which I owe to Dr. Crampton : 

i. Rising as soon as awake. Throw the bedclothes over the foot of the 
bed. 

2. Breathing and setting-up exercises appropriate for the grade. 

3. Washing, hot water, soap and scrubbing brush on face, neck, hands and 

chest. Cold douche on face, neck and chest. Cleaning ringer nails. 

4. Brushing the teeth. 

5. Dressing, with inspection of clothes as to cleanliness. 

6. Preparation for breakfast. A few minutes in the fresh air if possible. 

Cleanliness of napkins and utensils. 

7. Eating slowly and mastication. 



8. Attention to toilet and washing afterwards. 

9. Preparation for school. Books and clothes are clean and in order. 

10. Observe regulations as to entering school. 

11. Care of outer clothing and attention to order of desk and preparation 

for inspection. 

12. Sitting posture and standing posture in school. School room hygiene. 

13. Drinking water at recess. 

14. Return to home for lunch without loitering. Washing before lunch. 

Eating slowly. Preparation for school. Books and clothes are 
clean and in order. 

15. Play and fresh air after school. 

16. Lessons. Pay attention to study and finish the work. 

17. Washing and preparation for evening meal. 

18. Preparation for bed. Attend the toilet, wash, put clothes in order, 

open window. 

In these four grades entire frankness with regard to all the 
natural operations with which the child is familiar in himself, 
or in the animal pets with which he plays, will conduce to genuine 
refinement of thought with regard to these operations through- 
out life, and make easily practicable a similar method throughout 
the school course. 

Physiology here will deal only with so much of the body as 
is manifest to view, and will discuss rather the effects of healthy 
conduct than the internal conditions of digestion, etc. 

As many children leave school at the fifth grade, we must in 
this grade systematically endeavor to bring the child life into 
contact with as much of the world's life as is feasible and suitable. 
The school equipment is studied and the janitor may be brought 
into service, to make the boy feel the interest which a man of 
the world takes in such matters as ventilation, cleanliness, etc. 
The home life is discussed. The care of the streets, lighting, 
water and sewage supply are brought to the child as phases of 
his present life. The treatment by city and state of contagious 
disease is brought within his sense experience, and so dis- 
cussed. 

Upon the basis of this hygienic attitude towards his present 
life, the boy learns as much of physiology as he needs in order 
to understand his present life, of which knowledge the details 



8 4 

may be forgotten, if these principles stay in remembrance: i. 
The delicacy of the bodily structure and the persistent accumula- 
tive effect upon it of sickness and abuse. 2. The effects of all 
forms of exercise upon habit and growth. 3. The essential 
notion of bacterial infection. 

The instruction in hygiene during the next three grades, the 
last of the common school, is called the intermediate. It is the 
standard course of the schools. The same general tendencies 
seem to be observable here as in the elementary grades. What 
is taught is to be not so much physiology, even applied physiology, 
as hygiene practised and explained; and hygiene is to mean 
not so much the science of keeping well and living long, as the 
knowledge of what it actually means to live efficiently. 

In these grades in many schools the boy and girl, through 
civic leagues, and associations for the use and beautifying of 
vacant lots, come in close contact with the activities of the town 
or city, and are in a position to consider the operations of the 
health, fire, police, building and street cleaning department 
as parts of thier own lives. Hence they can be instructed in the 
means used in fighting disease, looking on the whole matter as 
a social enterprise, and not as an individual fear. Objectivity 
of attitude is thus still maintained. 

Excellent series of text-books and supplementary readers 
are now ready for the schools, if only the teachers were ready 
for the books. But it is a fact easily verified that there are 
many teachers who have the greatest difficulty in understand- 
ing even these simple books, and who know nothing beyond 
them. I would not say that the majority of teachers are in 
this condition, but I am tempted to say it. 

With regard to these text-books, one defect of importance 
seems to me to be the failure to make the city boy aware of the 
great differences between his life and occupations and those of 
the farmer's son. An understanding of the hygienic aspect of 
civilization is largely the understanding of this difference. It 
is treated but lightly at the best. The country boy and girl 
have to learn above everything the care of plant and animal 



life, and they see food on the hoof and on the stalk. Many 
absurdities of a false refinement would disappear before an en- 
lightenment as to those occupations and processes which lie at 
the basis of our civilization. 

In so far as I have endeavored to study the topics which should 
appear in a course in hygiene, I have been so impressed by the 
adaptation of some recent text-books in hygiene to individual 
and social needs, that so far as the selection of topics is concerned, 
I wish it were appropriate simply to name some of the best of 
these works. A criticism to which they in most cases lie open, 
is, I think, the discussion of individual health, in the sense of 
keeping well and living long, as though it were the natural aim 
of a school child. The tendency to regard the teaching of hygiene 
as a matter of information often leads even the best of these books 
to give information of little value or interest. To say that tobacco 
kills fish is to invite the boy's rejoinder that so does fresh air. 
Pictures of centenarian women and a boy tidy but sad are not 
adapted to the end in view. I have mentioned what seems 
to me a serious omission, the failure to contrast sufficiently 
civic life with the life of the farm boy. These text-books agree 
even more in what they omit than in what they include. 

Emphasis upon the need of regular excretion, upon proper 
precaution at toilet, and perfect frankness in dealing with the 
lives and propagation of the school flowers and pets are demanded 
by the child life. The idea that ill health is a kind of immorality, 
and that it commonly means infection may be relied on to sug- 
gest much. 

According to statistics prepared for the American School 
Hygiene Association, in 1910, only 8 per cent, of our high schools 
give credit for hygiene, only 18 per cent, prescribe the teach- 
ing of hygiene, only 5 per cent, require gymnastic work, only 
1 per cent, compel students to pursue some form of athletics, 
or give credit therefor. Had answers been received from the 
smaller schools the statistics would have shown conditions even 
worse. 

The reason commonly given for not requiring hygiene in the 
high schools, or giving credit for it, is that it has already been 



86 

pursued ad nauseam in the grades. The tendency as I have 
just shown is to eliminate much of this repetition in the grades, 
which can be done without breaking the laws on the subject. 
A study of the text-books for hygiene show how much material 
of great interest may here be introduced for the first time; and 
the whole point of view of the boy or girl is different. Every- 
thing, however, will depend on the enthusiasm and knowledge 
of the instructor. 

But a half year, or even a whole year, of hygiene and physiology 
will not solve the extremely difficult problems of high school 
hygiene. High school students commonly cease to be under 
the direct control of any one teacher and are suddenly given 
unaccustomed freedom. At home they begin to assert inde- 
pendence and demand or acquire pocket money. Something 
of the wholesome boisterousness of childhood often gives way 
to less wholesome forms of pleasure. Absurd and injurious 
practices in food and dress, insufficient exercise and sleep become 
more common. Less than 25 per cent, of the children take any 
part in athletics, at least in the high schools I know best. It 
is extremely likely that both boys and girls will fall into bad 
personal habits. 

How may hygienic influences be exercised upon high school 
students? We wish to see every boy and every girl living in 
the presence of a school sentiment which will stimulate them 
to make the best of themselves to develop capacities for the good 
and the credit of the whole school. In other words, we wish 
to depend upon a form of student self-government and democracy, 
such as led Greece and Italy, in the days of the first and the 
second adolescence of humanity, to the realization of the finest 
types of personality in the city state. Such a method of teaching 
hygiene succeeds naturally in the high school to the system of 
instruction which has been described for the grades ; but I feel 
it to be useless to enter further into a matter which is at the 
present time largely theoretical. If there is any school which 
earnestly follows such a plan, I have failed to learn about it. 

At least the teaching of physiology and hygiene in every 
high school by competent and earnest men would seem possible, 



87 

and profitable, and in some states mere conformity to the require- 
ments of the law. 

If there is an emergency at this time as regards venereal disease 
may we not lay it down as fundamental that emergency measures 
should not enter into the building up of the school course. The 
development of the school is vital, organic, and can not be twisted 
about to meet emergencies. In the press, in parents' associations, 
industrial and public lecture courses we have means to teach 
what will spread as rapidly as vicious gossip spreads. The 
school may proceed to develop along the lines which child nature 
suggests to the educator. 

Our American plan of coeducation seems to make inadvisable 
the European methods of dealing with this matter. If the hygienic 
conception of school life itself is worked out, to mean complete 
living at the stage of the child's development, our boys and girls 
will have the abiding influence of the memory of having lived 
under conditions where kindly sentiment should develop without 
the sex relation once coming to the center of attention. This, 
combined with that frankness of speech in all matters that natur- 
ally enter the child's life, from the first grade on, are, in my judg- 
ment, the answers which the school gives to this problem. In 
all these matters provide wholesome conditions and follow the 
child's lead. Tell him what he asks you about. 
* I have endeavored to show how in some ways the school may 
in the period devoted to teaching hygiene bring to the focus 
of the child's attention all those factors which properly employed 
by the child will make his school life an efficient and a happy 
one. This involves, as I have said, the power of the teacher to 
grasp the whole school curriculum and school life as a means to 
the proper realization of the child's powers which is, properly 
speaking, health. It is an ideal which requires teaching of a 
high order. 

I have already referred to the insufficient preparation of our 
school teachers to teach hygiene intelligently. At the last 
meeting of the National Education Association, the department 
on school hygiene declared that the normal schools were almost 
universally failing to keep pace with the progress in school hygiene. 



88 

The head of a normal school declares that the normal schools 
are asleep, as far as hygiene is concerned. In 1910, 60 per cent, 
of normal schools required students to study hygiene, 68 per cent, 
require them to take gymnastic exercise, and 1 1 per cent, require 
work in athletics, 43 per cent, have athletic fields, 61 per cent, 
have gymnasia, 58 per cent, have tennis courts, 53 per cent, 
have a department of physical education. But only 36 per cent, 
had medical examination of students; only 29 per cent, gave 
courses in play ground management. 

We see how far in advance normal schools are of high schools 
in this matter. Yet it is but the other day that a normal school 
graduate, and from a good normal school too, assured me that 
a spring of water rising under a house was all right, since it tasted 
all right. 

But there are several gentlemen present prepared to speak 
upon the work of the normal schools. 

DISCUSSION. 

Principal F. D. Raub, Allen town, Pa. : 

Modern text-books on this science differ largely from those in use years 
ago. Publishers are ready at all times to cater to their trade like all other 
manufacturers and shape their products to meet the demands and require- 
ments of the purchaser. Formerly the text-books on this subject discussed, 
in a technical manner, the human body, but at the present, works on this 
subject present £he matter from a hygienic standpoint, calling attention 
to the attainment of a knowledge of preserving the body in a healthy con- 
dition, and increasing the strength and vitality, if at all weakened by any 
cause. The tendency of the medical profession is to educate the laity, to 
preserve and maintain a bodily vigor capable of coping with the varied 
conditions met with in life. If in the schools, the pupils can be imbued 
with the importance of preserving and attaining a certain manner of life 
conducive to good health and a vigorous body, much will be accomplished 
to render the possessor a happy and useful member of the community. 

The nation and state are putting forth great efforts to safeguard the health 
of the people, and it is but proper that the public schools should perform their 
duty in disseminating truths which tend to a proper appreciation of attaining 
and retaining a health} 7 body. In the primary grades the instruction is 
necessarily oral, and instruction of a kind comprehended by a primary pupil 
must be furnished. Some of the features introduced at this time are care 
of the body, including correct position in sitting, standing, walking, etc. 
The importance of the care of teeth can readily be understood by the child, 



8 9 

and attention given that the instruction is carried out. Cleanliness of face, 
hands, body, including clothing worn can be dwelt upon. The kind of food 
necessary and the avoidance of such that is unnecessary and unwholesome 
must be taken into account. 

The necessity of fresh air, and pure water can be readily understood and 
explained. The use of the special senses and the care of certain sense organs 
can be judiciously dwelt upon. Proper breathing exercises can be intro- 
duced and the importance of same can be enlarged upon. 

These facts and others can readily be taught in the primary grades, but in 
the grammar grades more of technical detail can be presented and made 
intelligible, always bearing in mind the necessity of inculcating good health 
habits and impress the pupils with the fact that much of their happiness and 
success in life largely depend upon the formation of habits of breathing 
properly, eating, sufficient exercise, etc., which will insure the development 
of strong healthy bodies. 

It would be unfortunate, however, that pupils should leave or pass the 
grammar grades, not knowing the different organs and parts and functions 
of same, and if the study is continued in high school these facts should re- 
ceive attention in connection with a knowledge of the general structure and 
anatomy of the human body, so that tbey may have an intelligent conception 
of the same. 

Dr. M. P. B. Groszmann, Plainfield, N. J. : 

I was deeply interested in what Dr. Hughes said about the necessity of 
developing in children the proper habits of life: the daily routine, the matter 
of baths, the care of the teeth, etc. It is particularly necessary to work 
along those lines with children who are not absolutely normal, not only the 
feeble-minded but also the backward. Atypical children require a g-eat 
deal of care in that particular direction. Much of the possibility of re- 
deeming the atypical and the backward child depends upon the proper 
training in daily habits. That is the reason I have sometimes suggested that 
the special class alone will not wholly solve the problem of the atypical child, 
but that we need some kind of institutional care for such children. In my 
own work I lay even more stress upon the development and training in this 
field than upon the school instruction; in fact I go so far that I do not en- 
courage the employment of any teacher who will not be able to give physical 
training and who will not be ready at any time to take physical care of a 
child. This coordination of the physical care and the training in proper 
hygienic habits which reflect upon the mental and moral attitude, I consider 
extremely necessary, and I think we should be thankful to Dr. Hughes for 
calling attention to this point. Our text-book work will avail very little 
without it, especially as we have so very little control over the home con- 
ditions of these children. If we could have that, then perhaps the training 
in a specially regulated environment would not be so necessary. 



90 

Dr. Helen C. Putnam, Providence: 

I am sorry not to have heard the two preceding papers, as I have just 
arrived, but perhaps what I wish to say has not already been said. 

It does little good to recite health maxims while under unhygienic school 
conditions. Our colleges and universities where teachers are trained, and 
especially our schools, are forcing beds for certain forms of ill health, because 
of their dust, high temperatures and aridity, all included under the general 
terms uncleanliness and bad ventilation. They should be as clean as a well 
kept home. No good housekeeper has the dirty floors and bad smelling 
rooms with which we shut in children and teachers. The law compels many 
of them out of well kept homes into these surroundings. As a result the 
death-rate among teachers from tuberculosis is higher than the average 
death-rate from tuberculosis, and higher than in any other profession. Those 
administering teachers retirement funds state that the majority retire before 
reaching the old age limit because of ill health, usually anemia, lung and 
nerve troubles — all the accompaniments of bad air, the so-called "bad air 
diseases." The tuberculosis death-rate increases all through school years 
and immediately after, until at the years of marriage and parenthood it is 
the commonest cause of death. There is only one kind of school that seems 
to check the "bad air diseases," the open air school. Here, doing the same 
school work, fragile and even tuberculous children invariably improve in 
health, at the same time catching up with their classes in the regular school 
where some were laggards because not strong. But children have to be 
poorly first, before school authorities will give them these sanitary schools, 
as they have to be arrested and tried in court before they can have industrial 
training and other educational advantages to be found only in our reform 
schools. Autopsies on children who died from scarlet fever, diphtheria or 
other diseases where tuberculosis was not suspected find over one-third to 
have had latent tuberculosis. This justifies the belief that many delicate 
children are in similar condition, and accounts in part for the efficacy of open 
air schools for all such children. 

A large percentage of school rooms have no thermometer; another very 
considerable percentage have thermometers that do not work; and in the 
schools I have visited having them in commission I have never found them, 
with very few exceptions, under 72 ° in winter months. Very frequently 
I have found them in the 80s. In a few memoranda of temperatures in 
college and university libraries 76-80 is the favorite condition. It is no 
wonder that our vital statistics are below those of other countries when 
authorities train people to these habits. 

The janitor is a most important factor in children's health. He lays the 
foundation of national vitality, educating health habits in the home-makers 
of the future, setting our standards of ventilation, cleanliness, temperature. 
But janitors are not even housekeepers. They are men with no pretense to 
training in house-cleaning methods, much less in simple hygiene and sanitation. 



9i 

Their salaries are often higher than those of elementary teachers and even 
principals who spend years in fitting for their work and undergo official 
testing and retesting, and whose health while engaged in their vocation is 
at the mercy of ignorant men with the results I have quoted. 

We need training classes for janitors. Candidates for janitorships should 
be examined in sanitary methods. Those cities where janitors are included 
in civil service laws do not yet do this effectively — the men have no place to 
qualify. Janitors' routine work should be measured by instruments of 
precision, as thermometer, hygrometer, anemometer, etc.; and they should 
be dismissed for failure to keep conditions up to standard as shown by per- 
manent records. One of the best ways to teach children hygiene is to have 
them take and record these observations. Experiments are under way along 
all these lines. They should be supported by physicians, who should in- 
sistently urge trained caretakers of health conditions at school. 

Dr. J. B. Tuckerman, Cleveland: 

In comparing statistics we need to exercise care. I do not believe that 
statistics will show better conditions in Germany than here. I am not 
questioning the Doctor's statement in regard to the bad conditions in school, 
but I think we have to be a little bit careful in taking and interpreting 
statistics. 



X. 

TEACHING OF HYGIENE— METHODS IN VOGUE. 1 

By W. S. Steele, A.M., LL.B., Harrisburg, Principal Harrisburg High School. 

As a graduate of a college classical course coming out at a time 
when the teaching of any of the sciences in classical course was 
little more than mere memory training, but slightly experimental 
and investigative work, I am at a loss to understand why I am 
asked to take this subject. Because it is certainly not my spe- 
cialty I make no claim to originality in this paper. While I have 
not copied consciously the language of any body, I have taken 
the substance from any sources at hand. I am especially indebted 
to two of my own teachers both from observation in their class 
rooms and from actual conversation about this very subject. 
I may also trespass upon the line of thought of my successor 
upon this platform because the line of demarcation between 
what actually is and what ought to be educational thought all 
over the country is isothermal rather than longitudinal. What I 
may consider as actually in vogue may only be suggested elsewhere, 
while on the other hand I am sure that what we know is that 
the correct practice cannot be carried out in our present 
crowded building. 

This question quite naturally separates into three main divi- 
sions : 

(a) Definition of Hygiene. 

(b) Importance of Hygiene. 

(c) Methods in Use in Teaching Hygiene. 

DEFINITION OF HYGIENE. 

Possibly it is superfluous to give these definitions before an 
audience composed largely of physicians, but I am thinking of 
that portion of the audience which does not distinguish between 
physiology and hygiene, or between hygiene and anatomy. 

1 Read at the Conference on the Conservation of School Children, Lehigh University, 
April 4, 1912. 



93 

i. The science which tells how to keep living bodies in good 
condition or working order, or 

2. That teaches the art of preserving the health and preventing 
disease. 

3. That treats of the laws of health, how to care for, how to 
use and how to nourish the body. 

IMPORTANCE OF HYGIENE. 

Under this head 

1. It is necessary for the present and future health of the body. 
A thousand illustrations might be given but a few are sufficient. 

(a) It teaches one how to avoid taking cold, and tells us that 
a neglected cold may lead to something worse, (b) It teaches 
the causes of such diseases as yellow fever, typhoid fever, tuber- 
culosis and malaria. Historically it may tell us that neglect 
of what are to-day the most common measures of prevention, 
sent millions to avoidable death in ancient times, (c) It teaches 
what to do in case of such injuries to the body, as a broken arm 
or a cut blood vessel. 

Army surgeons, as you know, declare that in most wars before 
the present century ignorance of the laws of hygiene resulted 
in more deaths than did the bullets of the enemy. 

2. Hygiene is of economic importance. 

(a) Before 1796, in cities having a population of 100,000, 
more than 2000 cases of small-pox occurred every year resulting 
in hundreds of deaths. 

Boston, in 1721, with a population of 11,000, had nearly 6000 
cases of small-pox. Eighteen thousand people died in Iceland 
of this disease during 1 707-1 709. It is now one of the rarest of 
diseases. 

Yellow fever, which once practically depopulated whole districts, 
is now under almost absolute control. Malaria is no longer 
dreaded. Tuberculosis will be conquered before the dawn of 
of the 21st century, probably much before. 

(6) About one-quarter of all children die in the first year of 
life. This is due largely to ignorance and carelessness. Bad 



94 

sanitation and poorly lighted and ventilated living places, that 
are the result of poverty which in turn may be the result of dissi- 
pation and excess of one sort or another, may contribute to this 
death-rate. 

j. Hygiene is necessarily a part of school requirements. 

Because: It is the only place where many children can be 
taught the means of taking care of themselves. The very child 
that needs the most to know this often comes from a home where 
there is absolutely no chance to learn it. I need not expand this, 
the same reason compels the public school sometimes to do both 
parental work and Sunday-school work in addition to its own 
proper work. The child who must work for a living needs to 
know the necessity of good plain food ; needs to know how to 
care for his body if he ever expects to accomplish anything by 
his work. 

4. It has an ethical value. 

It ought to arouse a wholesome respect for the Creator, by show- 
ing the wonderful coordination of all parts of the body. 

METHODS IN VOGUE. 

Technically speaking, I have just come to my real subject. 

1. Let it be clearly understood that to-day in any modern 
school taught by a trained teacher and equipped with all that 
it should have, the text-book is only an aid. The old way was 
the memory way, admirable for poetic gems but practically use- 
less for life knowledge. 

I grant that we learned a few facts, but while we remained 
thoughtless boys and girls we never applied the facts. To-day 
a text-book is the place to start the subject but by no means the 
place to end it. 

2. Some knowledge of anatomy and physiology is essential — 
enough is taught to aid in the study of how to take care of any 
organ of the body just as the simple mechanics of a wagon or an 
engine endears that toy to a boy and make him more careful 
of it. This is taught to-day in practically all schools by the aid 
of skeletons, manikins, artificial e}^es, charts, etc. 



95 

3. Comparative anatomy: In connection with the structure 
or use of an organ there is a fine opportunity to make a compari- 
son of that organ with the same organ in animals, though 
perhaps not so much of this can be done until we reach the higher 
grades or the biology classes in the high school. 

There are many valuable books dealing with this phase of the 
subject which may be used as a means of broadening the view, 
helping to develop an interest in zoology and a desire for studies 
given later in the course. Wholesome curiosity left for the moment 
unsatisfied is believed to be worth much because it excites more 
spontaneous study than any amount of talk about the wonders 
of the same subject. 

4. Drawings: Now that so many fine drawings and diagrams 
are available at low prices, the study of hygiene is considered 
incomplete without their aid. But only simple drawings such 
as can be accurately copied by classes should be used. There 
is a ps)'chologic reason for the use of drawings : the eye can be made 
to assist the brain in remembering and understanding. I may 
add, too, that the copying is of some small value at least in train- 
ing the hand. A visual memory is of very great value for it 
saves much time and labor. 

Closely correlated, if I may use that term here, with visual 
memory are interesting and picturesque verbal illustrations. 
Psychologists insist that much of memory labor might be saved 
if facts were expressed to pupils in a sufficiently striking manner. 
Many books, such as Mace's "History of a Mouthful of Bread" 
and Foster's "Physiology," abound in apt and interesting illus- 
trations such as: "The villi, little tags, like very little tongues 
hang down into the intestine." "The liver is the master rag- 
picker of the body." "Fat is the savings bank of the blood." 
"Blood is the circulating market of the body." 

5. Scrap Books: If we urge pupils to collect and preserve 
in scrap book form, odd facts about physiology and hygiene, 
we believe we are urging them to quicken and strengthen greatly 
their powers of observation. There are many sources for such 
material, such as scientific magazines, medical journals, and even 
the circulating monthly magazines. Of course, lack of time 



9 6 

will prevent a teacher from accomplishing all of this sort of 
thing that she would like to accomplish. Also many lazy pupils 
can never get beyond what is actually brought and forced upon 
their attention. 

6. Recitations may be used to improve English. There is 
no better chance to develop clear concise English. All sciences 
call for sharp distinction, nice shades of meaning and accuracy 
in expressing of facts, as well as in the facts themselves. 

7. Even mythology has its place. Such an expression as 
"The Tendon of Achilles" gives a chance for satisfying curiosity 
in the best of all ways by inducing the pupil to hunt the reference 
library. 

8. Experiments: There is no reason why pupils should accept 
the statement of the books that bones in old age break more 
easily than in youth, or that children should stand straight so 
that they may not grow round-shouldered. Prove these state- 
ments by experiments. Have pupils burn a bone and discern 
that it crumbles into powder that is really lime, or the mineral 
matter that makes a bone easy to break. The statement that 
this mineral matter increases with age clears the text. Breathe 
into lime water and the clear, pure liquid becomes cloudy, show- 
ing the presence of impurity known as carbon dioxide. 

I will close this paper with a summary of how physiology and 
hygiene are taught in one of the best equipped schools in the 
country — best equipped, I mean, for the study of the sciences. 

In the first four grades instruction is oral on the following 
topics : 

(1) Cleanliness and neatness, including the care of the hair, 
teeth, nails and face. 

(2) Eating, including kinds of food, harmful effects of cheap 
candy, of overeating, etc. 

(3) Pure air and how to breathe. 

(4) Physical exercise, sleep and rest. 

(5) Alcohol and tobacco and simple lessons on parts of the 
body, including bones and muscles. 

In grades 5 and 6 an elementary text-book is used which de- 
scribes briefly the important organs in the body and their posi- 



97 

tions and functions. At this stage there is added, after a review 
of former work, instruction in caring for bruises, cuts, sprains, 
burns, poisonous bites and stings. Some of the common diseases 
are described and the methods of treating and preventing the 
same. The effects of alcohol and tobacco are emphasized because 
of their importance at this stage. 

In the 7th and 8th grades a more advanced text-book is used 
which includes a discussion of the skeleton, muscles, skin, diges- 
tion, food, circulation, respiration, exertion, nervous system, 
special senses, voice and speech. In each section regulations 
are suggested for preserving the health of the organ, including 
the special effects of alcohol and tobacco. In the first year of high 
school there is a review of former work with the addition of 
laboratory work, where possible, and practical applications to 
life in and about our large cities. Food and water inspection, 
sewerage, street cleaning and garbage disposal, medical inspec- 
tion and quarantine form a part of the course. Laboratories 
equipped with microscopes make possible some elementary work 
in bacteriology. A study of the life, history, birth, and growth 
development, reproduction and death and the relations of animals 
to other animals and to us, enables the young student to appreciate 
the significance of the body and gives him a clear brain to ade- 
quately discharge the duties and responsibilities of life. 

Where possible, students of biology and students of all con- 
ditions that make for health should be taken out to see things 
in concrete form. They should visit a filter plant, a garbage 
disposal plant, should see under the microscope some of the things 
that attack the human body and destroy the health. It is 
not in my opinion very likely that children in the grades can be 
made to understand much of bacteriology, but they can be made 
to see that there is danger in the cup. They can be taught that 
the bite of a fly or of a mosquito may be worse than the bite of 
a dog. They can be taught that expectorating anywhere is 
dangerous. How they shall be taught we must leave to the 
teacher. The live ones will teach it. The dead ones will teach 
these no better than they teach anything else. 



When I was a boy nobody told me that old age is merely the 
hardening of the arteries. If we can bring boys and girls to 
see that physical exercise is necessary in order to keep these 
arteries from hardening, that overstraining the heart is not 
good physical exercise, that to eat too much and to drink too 
much is simply to overwork the organs of elimination and thus 
bring on various ills; if we can teach the youth how to live phys- 
ically we are not only making him a more efficient engine in the 
great factory of life, but we are creating a disposition that will 
be agreeable to associate with and may perhaps prepare a better 
field than we realize for the dropping of spiritual seed. At what 
age the boy comes to the full knowledge of himself and the full 
vow that he will cultivate and conserve himself must depend 
first on the boy and second on his teachers, whether in the school, 
in the house, or in his environment. 



XI. 
HOW SHOULD HYGIENE BE TAUGHT? 1 

By Louis Nusbaum, Philadelphia, District Superintendent Philadelphia Public Schools. 

No subject can be successfully taught unless there is a clear 
perception of the end in view. For years we have been groping 
in the dark in our teaching of physiology and hygiene, lacking 
a definite purpose and a definite point of view. We have been 
treating the subject as an independent and isolated study, un- 
related to any other subject in the curriculum, and unrelated 
to the real things of life, while in fact no study bears a closer re- 
lation to the daily activities of the community. The subject 
is generally disliked by pupils and by teachers. There is every- 
where a tendency to avoid, evade and curtail whenever possible. 
Teachers fail to observe the requirements of the law concerning 
the subject which is usually regarded as dry, uninteresting, 
and unintelligible. 

Section 1609 of the new school code reads as follows: 

Physiology and hygiene, which shall in each division of the subject so 
pursued include special reference to the effect of alcoholic drinks, stimulants, 
and narcotics upon the human system, and which shall also include special 
reference to tuberculosis and its prevention, shall be introduced and studied 
as a regular branch by all pupils in all departments of the public schools of 
this Commonwealth, and in all educational institutions supported wholly 
or in part by money from this Commonwealth. 

Except for the reference to tuberculosis this section has been 
substantially the state law since the act of April 2, 1885. 

Although the law has provided ample scope for the teaching 
of practical hygiene, until very recently it has been so narrowly 
interpreted that our courses of study have become conservatively 
fixed in a groove now somewhat difficult to break away from. 
In attempting to teach the subject in this limited way in all 
grades, the educational authorities have undoubtedly had to face 
a difficult problem in providing material enough to spread over 
an eight-year or a twelve-year course of study. This accounts 
for the inordinate extent of our teaching of the subject, as well 

1 Read at the Conference on Conservation of School Children, Lehigh University, 
April 4, 1912. 



IOO 

as for the necessity of persistent repetition of the same material 
in the several grades, due to insufficiency of subject matter. 
This combination of circumstances is no doubt responsible for 
much of the child's aversion for the subject. A prominent physi- 
cian who has sent his children through the public schools of 
Philadelphia, and who, as a teacher, is generally interested in 
public education, once said to me that our elementary schools 
were spending more time in teaching anatomy and physiology 
than is given to these subjects in our good medical schools, and 
his feeling was that in their zeal to omit nothing, teachers were 
attempting to present their subject with as much particularity 
as most medical school instructors might. 

Before discussing how the subject should be taught we ought 
to have clearly before us the purpose of our teaching. This seems 
to be twofold — first, to secure to the individual a sound body, 
which in turn will tend to increase his happiness, efficiency, 
and longevity. In an indefinite way this has been the purpose 
generally recognized in schools, though in treating this phase 
of the subject the child has scarcely been made to realize that 
there is a study of hygiene which presents matter of vital interest 
to him, and which comes within the range of his daily experience; 
that there are things which he can and should observe and apply 
for himself; that he will thereby serve his own greater good. 
Next, there is a social aim of this teaching. In a, broad sense 
this is probably far more important than the other, and yet, 
in most cases, it has been almost overlooked, or if approached 
at all, has been presented in preachment or in hysterical oration. 
Without entering into a discussion of the aims of education we 
may all concede that one of its important functions is to prepare 
the individual for his place in the community, and in this connec- 
tion he must be so prepared that he will help, and not jeopardize, 
the interests of the organism of which he is a part. He must 
aid in the perfection not only of his own happiness and efficiency 
but also of the happiness and efficiency of the society in which 
he lives. 

With this point of view as a place of departure it may be de- 
sirable for us to examine some things to be avoided in order that 



IOI 

these ends may be attained without arousing the child's opposi- 
tion, whether conscious or otherwise. The subject must be freed 
of technicalities which do not interest but only confuse the child. 
As physiology has been taught in the past we have endeavored 
to present a vast amount of unattractive anatomy of the human 
system, fitting in the functions of each organ in its precise place. 
Most of the anatomy and much of the physiology should be elim- 
inated. Of what interest and of what possible value is it to 
a child to know the anatomic differences between arteries 
and veins, or to understand the action of the valves of the heart? 
What purpose is served by attempting to teach a child the struc- 
ture of the stomach, or the particular function of each portion of 
the digestive tract? What folly to try to explain to him the chemical 
changes in the food in process of digestion, or of the air in respi- 
ration. The illustrations might be multiplied almost indefinitely. 
Again, we must avoid attempting to give didactic moral in- 
struction concealed under cover of technical physiology. Children 
are keen to discover subterfuge and hypocrisy. We must be par- 
ticularly careful to avoid exaggeration in our presentation of 
the subject; and much of our teaching, particularly with refer- 
ence to the effects of alcohol and tobacco, has been exaggeration, 
if not directly, by implication. The child is often able to satisfy 
himself from his own observation that much of the particular 
result attributed to these agencies is not a fact, and he loses 
confidence in the teaching given. We must avoid arousing the 
opposition of the child by seeming to present an indictment against 
those in his own home who may be users of alcohol or tobacco. 
Such teaching creates a community sentiment against the work 
of the school, and proves to be a real hindrance to the accomplish- 
ment of the desired result. If we would teach temperance in 
all things, we must be temperate in our teaching. It makes 
a vast difference whether we present to a child as a universal 
proposition that drinking alcoholic liquors weakens heart action, 
destroys digestive power, creates flabby muscles, deadens the 
nerves, etc., with all the minute detail of physical and physio- 
logic changes involved, or whether we tell him that he ought not 
to drink alcohol because the habit of using alcohol grows in- 



102 

sensibly on one, causes the squandering of money often needed 
for other things in the home, is apt to lead to associating with 
others who indulge in similar habits, the loss of self-respect, 
perhaps even the planning and execution of evil deeds, and so 
forth, and so is a meaace to the community as well as a personal 
sacrifice. So far as the intellectual appeal concerns the child 
it is apt to fall flat as an incentive to action, partly because he 
fails to comprehend the significance of the instruction, and 
partly because most children in school are at a heroic age when 
martyrdom even to an unworthy cause is often alluring; but 
the moral and social phases of the subject, properly presented, 
can scarcely fail of effect. 

What we need at this time is to teach hygiene and sanitation 
with a background of physiology instead of teaching, as in the 
past, physiology with a foreground of anatomy. As isolated 
fact it is immaterial to the child whether there are two hundred 
and six states in the Union or forty-seven bones in the body. 
He used to study his history by memorizing chronological tables; 
his language by definition, declension and conjugation; his 
geography was the old-time "sailor geography;" and his physiology 
during all these years has been in keeping with methods now 
discarded in these other subjects. 

We want to get as far as possible away from the teaching of 
physiology whose only appeal is to the intellect, and particularly 
to an intellect unprepared for such an appeal. We must remember 
that physiology is a study of the most difficult phase of the most 
delicate and most intricate mechanism of which we have any 
knowledge. Properly treated, the subject has a great big message 
worthy of the activities of every child whose body is full of good 
red blood, and the presentation ought to be such as to appeal 
stirringly to the interest of each one. We have before us a vast 
body of material with which to do a real, big, practical work, 
and whether we achieve a result will depend upon the way we 
present this material to the child. We are more completely 
realizing each day that teaching by example, if not too obtrusive, 
is one of the most effective methods of teaching, and so we are 
making the modern school, by its very appointments, an incentive 



103 

to sanitary and hygienic practices. We provide large airy, 
well ventilated, well lighted class-rooms, bringing the light from 
high windows at the pupils' left, and shutting out cross lights. 
We tint our walls and ceilings with tones pleasing and restful 
to the eye. We provide well ventilated lockers for the children's 
clothing, so arranged that they are ventilated to the outside 
air rather than to the class-room. An unfortunate omission in 
school architecture, except in a few cases, is the failure to provide 
means of isolating a child's clothing from that of his neighbors 
in the locker. Our class-rooms and corridors and sometimes 
our stairs are constructed with rounded sanitary corners and 
bases, anti-dust- collecting, and anti-germ-collecting. We are 
providing corridors with concrete floors and tiled walls so that 
they may easily be flushed out and cleaned. We are oiling 
floors, so as to bind the dust, thus reducing materially the number 
of germs floating about in the air. We are providing well lighted, 
well ventilated, automatic flushing toilets, so that even in private 
filthy or immoral tendencies are routed out by cleanliness, sun- 
light and decent surroundings. Schools are providing baths, 
healthful lunches, medical inspection, nurses' services, open air 
classes and cold-room classes, and everything about the modern 
school tends to the creation in the child's mind of an ideal of sani- 
tary living. 

Having established an ideal the school's next effort should be 
directed toward aiding the child in the accomplishment of his 
ideal. No teaching of a practical subject is worth while unless 
it results in action, and so our teaching of hygiene needs to be 
made of a kind which will result in deeds — not a kind to be read 
about only in the school room as a wonderful and mysterious 
something — perhaps like an Aladdin's lamp, to be dreamed 
about — but never to be used out of school. The most vital factor 
in teaching hygiene which will be preventive as well as curative, 
and social as well as physiologic, is the teacher. This statement 
may seem to be so commonplace as not to deserve mention, 
but in order to teach the subject in such a way as is here advocated, 
and as we believe to be necessary, the teacher must in no ordi- 
nary degree have confidence and faith, and enthusiasm in her 



104 

work. So far as school life permits she must be the exemplifi- 
cation of her teachings by her own habits of punctuality, cleanli- 
ness, gait, posture, etc., by her attention to class-room ventila- 
tion, by her own manner of dress. She must believe in the value 
of the child's outdoor games and be willing to enter into them 
herself with spirit and enthusiasm, and she must act in such 
way as to lead her pupils to believe that she believes in her own 
teaching of the work. She can do much to arouse the child's 
activity and interest in health problems by appealing to his 
social instincts as suggested in Allen's admirable work on "Civics 
and Health." The class opinion and the school opinion will 
do more to secure individual cleanliness than any amount of 
exhortation or appeal to the intellect merely. The step is easy 
from cleanliness of clothing and body to cleanliness and general 
care of the teeth, the skin, the eyes, the posture. An intellectual 
background is necessary as we advance to the somewhat more 
intricate problems of health in order that the child may have 
an apperceptive basis to which he may relate his increasing ex- 
perience along hygienic lines. We might profitably make an 
intensive study of a few of the organs easily cared for, and easily 
abused, as, for example, the eyes, and the teeth, so that when 
the rules of health concerning these organs are violated the child 
will almost automatically appreciate the probable consequences 
of his acts and instinctively tend to correct them. 

After we have aroused the pupil's interest in himself as to 
mere appearance, the school may by unconscious steps lead him 
to an interest in those other matters which concern his personal 
health. He will be interested in teaching which tells something 
about the kind of food he eats and the proper preparation of his 
food; or which concerns the physiologic differences between the 
use of ripe and unripe fruit, for example. He will be interested 
to know why it is important that he should use pure milk, and to 
know something about the effects of using unclean or improperly 
kept milk, meat and other foods. Some slight study of micros- 
copy will give him a reason for desiring his drinking-water to 
be sterilized, his milk cans to be properly cleaned, his vegetables 
to be well cooked. Every child is a hero worshiper, and his 



io5 

idol is usually the athlete, the acrobat, the soldier or fireman — 
the person who by physical prowess is able to perform "wonderful" 
feats. This fact forms a point of contact with his physical 
exercises and games in school, gives him an incentive for a proper 
development of his body. Competitive exercises in school in 
which all may participate, and in which recognition is given for 
physical development and improvement rather than for individual 
excellence, often arouse a keen interest in proper care of the body, 
and in physical growth and expansion. If, on the practical 
side, the child is brought to realize that other things being equal, 
employers want to engage the services of healthy, well-formed 
boys, and usually desire that they shall not be cigarette smokers, 
the incentive for seeking proper health habits looms up formid- 
ably. An intelligent, fair and honest consideration of the subject 
of tuberculosis, its causes, its effects, and its treatment, its preva- 
lence, and its significance to the community, together with an 
exposition of the practical measures taken to combat the disease, 
will do much to correct unhygienic habits among the children. 
Once they learn the importance of plenty of fresh air, the matters 
of correct breathing and proper ventilation will receive due 
attention at home as well as in school. 

Any child can be made to appreciate his community responsi- 
bility in matters of personal habit, and he can easily be led to 
avoid such offensive practices as spitting by a consideration of 
the possible consequences of such acts when generally practised. 
He can be led to carry into his home the ideas implanted in his 
mind at school and thus serve as a social agent of reform. He 
can be brought to appreciate the harm done by allowing filth 
to accumulate in cellars or alleys, by crowding workers into sweat- 
shops, and by employing child labor in mines and amid other 
unsanitary surroundings, and he, collectively, will become a 
vital force in the future eradication of many such evils. By 
his own practices he will often be able to convince parents of the 
need of attention to decayed teeth, poor eyesight, obstructed 
breathing, constipation, or physical deformities. A brief intro- 
duction into the subject of bacteriology will perhaps lead hirn 
to give some wholesome advice at home as to the care of the baby's 



io6 

food, bottles, etc. Some simple, straightforward instruction 
concerning such topics as these and their immediate effect upon 
ourselves and those about us will often result in the creation of 
a set of personal habits which, when once definitely formed, will 
be almost as hard to break as it is difficult to depart from bad 
habits once formed. My little girl is not yet two years old but 
she has already formed the habit of using a tooth brush twice 
a day. She knows when the time comes to use it and asks for 
it. Her teeth are not likely to suffer in the future through lack 
of proper care. It may be objected that this is pure habit and 
has no relation to teaching, but it seems to me that our main 
purpose in a treatment of this whole subject is to cause the child, 
and later the adult, to live right habits, to rebel instinctively 
against offensive and unheal thful practices, and to make it in- 
creasingly difficult to break right habits in order to perform acts 
prejudicial to the health of himself and the community. 

If we will relate our teaching to the child's daily acts so that 
he will, consciously or unconsciously, seek to breathe correctly; 
so that he will habitually take proper kind and amount of exercise ; 
, so that he will sleep at seasonable hours, and in well ventilated 
rooms; so that his body and clothing will always be clean; so 
that his habits are formed with due regard for the health rights 
of others; if we can persuade him to be temperate and modest 
in all things, we shall be giving a kind of training which will 
result not only in personal health and happiness, but ultimately 
in increased health, happiness, and efficiency and improved morality 
of the entire community, we shall be educating these children 
not only to serve themselves and the community better, but we 
shall be laying up golden treasure in our future fathers and mothers. 

DISCUSSION. 

Dr. J. S. Grim, Kutztown, Pa.: 

The prior problem of getting teachers ready to properly present courses 
in hygiene is the main one with those in charge of the work in teacher -training 
schools. If the average teacher in our schools could translate into effective 
teaching the ideas just given, there would be little to complain of. The 
normal schools of this state more than any other single force are responsible 
for this antiquated type of teaching health. They are the agencies espe- 
cially designated by the state to spread abroad the gospel of right living; 



107 

they receive pecuniary assistance for this work and cannot, therefore, shirk 
entire responsibility if commendable work in hygiene and sanitation is not 
done in schools supplied by their graduates. A large majority of our schools, 
especially those in rural districts, are so supplied and there is a crying need 
of improvement in teaching power right here. 

I desire to speak of only one reason why our methods in vogue for years 
have continued practically unchanged. This reason is not intended to shift 
responsibility, but to explain a real difficulty facing any state normal school 
teacher who desires to keep abreast with the best thought as to content and 
method concerning the work in hygiene. 

Our normal schools are state institutions, but largely under local control. 
Our results in the class-room are reviewed by representatives appointed by the 
state. These reviewers or examiners, while able men, are frequently not in 
touch with the ideals of the several teachers upon whose work they are to 
pass judgment. If we were to teach according to some of the ideas sit forth 
here to-day, the examiner who frequently wants the names of bile pegments 
and the per cent, of water in enamel would not only be disgusted with the 
papers, but the moral effect on the student would be, after the chagrin of 
failure had passed, to view the teacher in an unfavorable light. 

The average training-teacher in this work is ready to proceed toward better 
things when you of the medical profession and you superintendents create a 
sentiment for a different type of examiner, a man who puts health first and 
anatomic details second and always second. Microscopic minutiae as an 
end will part company with interest unless the teacher is not only unusually 
strong but a trained biologist as well. 

No trainer of teachers, however, when the bodily vigor of children is at 
stake, should be daunted by difficulties or waver in the performance of the 
right. Good instruction will tell. An examination in hygiene of a prospective 
teacher should in some way include the bodily habits of the applicant, the 
carriage, the vitality, the sanitary ideals actualized in practice. 

I generally include in my course in hygiene a lecture on fresh air in the bed- 
room. On a certain occasion I made it a point to ascertain the locations of 
those rooms occupied by my students. Very early in the morning of the day 
following this particular lecture, I made a tour of inspection around the out- 
side of the dormitories only to find that ninety per cent, of all the students 
who on the previous day had apparently been impressed did not follow their 
instructions on the ventilation question. 

Some years ago I had a young man in class who was suffering from a bad 
case of adenoids. The nature and effects of these growths were explained 
in class. I spoke to this prospective teacher several times about his case 
in private, but the matter ended there. This young man is teaching school 
to-day, and very probably explaining all about adenoids under the extreme 
difficulty of talking about them because of them. 

I made a test of my students' eyes one week and I met a case of eye-strain 
that was well nigh pitiable. I spoke to this lady about the matter; I wrote 



io8 

her father, a man wide-awake in school affairs, and urged him to see that 
something would be done, but so far as I know the young lady has never 
taken treatment to this day. 

I would call these three cases exceptional. They are used here as instances 
of the difficulty of getting even prospective teachers to act upon the knowl- 
edge gained from others. 

The test of good teaching of hygiene, therefore, is not the examination 
test as an examination is ordinarily given. Action must follow discussion; 
the will must be moved toward better things; right habits of mind and of 
body must be formed. In the education processes it matters little whether 
a text-book is used or not, whether the work is done joyfully or joylessly, 
provided the teacher can point to cleaner and better bodies as a result. 

I asked a girl some time ago why she didn't like the study of physiology. 
Her answer was that she "hated to study about her insides." Last year one 
of my strong girls fainted in class at the sight of a drop of blood. Yet our 
text-books almost invariably tell us to go to the butcher shop for the heart 
of an ox, dissect it and show the main parts described in the book. No 
doubt anatomic data can best be acquired in this way, but did the Indians 
have weaker hearts than we? They surely knew nothing of their functions 
and structure. This query is really pertinent in view of this girl's repug- 
nance as regards the question of her "insides." If a compound micro- 
scope is at hand and a section of a part of the heart is shown, the peculiarity 
of the muscle fibers noted, is it supposed that the girl is apt to tone down her 
repugnance according to the degree of refinement in method used ? My friend 
might be absent from class next day, not because she didn't know whether 
the tricuspid valve was on the right or left side of the heart, not because 
she didn't know if these muscle fibers were striated or not, but because she 
caught a cold, had headache or some other little complaint that comes from 
violating nature's laws. 

If any person takes up the study of hygiene a stalwart and com letes a 
weakling, his course has been a failure. If this study does not strengthen the 
arm, give tone to the nerves, brighten the eye, lighten the step and make the 
student less incautious as regards the dangers of infection, it is very likely 
that the time could have been more profitably spent on some other subject. 

In our teaching of hygiene we have been spending too much time on the 
human mechanism — a machine that is exceedingly complex, whose funda- 
mental operations are too difficult for children to understand even though 
they were necessary, and we are spending too little time on the child's environ- 
ment. I have frequently detected symptoms in young people that led me 
to believe that they were on the danger zone of becoming hypochondriacs, 
resulting from unwise introspection. I have a young man at work now on 
our local water plant, having had a little chemistry he is testing this water 
for chlorine, ammonia and other substances. Following a few simple direc- 
tions he is using the incubator for certain pollutions. We began with an oil 
stove, a galvanized bucket, a few wide mouth bottles, a good compound 



109 

microscope and a few reagents. The charge cannot be brought against the 
young man that he is not interested. He is working on a few of the great 
problems of germ life and disinfection. 

If children see how and where the house fly breeds and what it does, they 
will not only be interested but soon create a sentiment for its extermination. 
There is nothing the matter with the study of physiology and hygiene. It 
is not dead. The teachers are frequently dead. The new course of study 
for the Pennsylvania State Normal Schools has this subject where it ought 
to have been long ago — after botany and zoology. More time is given to it. 
We will be in a better position to take our part in conserving child life, to 
arouse a more intelligent interest in the need of disinfection, and to prevent 
in a measure the needless waste in bodily vigor and efficiency. 

Miss Sara Phillips Thomas, Philadelphia: 

I believe the conscientious citizen and teacher are both awake to the 
necessity of the teaching that fits the child for life; we have come to a period 
in the history of our nation where we need to give to the children as never 
before the knowledge that will enable them to conserve their natural forces 
so that under the proper training those forces may be converted into energy 
and power that means the best development of the physical, intellectual and 
spiritual nature of the child in order that it may be of the greatest use as an 
individual in its relation to the home, community and state. 

Because we realize the need of this conservation and training for the child 
just as the state and nation have realized the need for the conserving of 
natural forces as they have been trained to do the bidding of man for the ad- 
vancement of the commercial world we would emphasize the thought that in 
order that the child may have the equipment for right living which comes 
with applied knowledge and the formation of right habits we must have the 
impersonal teaching of narcotics, including alcohol, which injure the health 
of the child, and with our many improved text-books, such as the Gulick 
Series, Davison's the New World Series and others, our charts and the great 
wealth of scientific facts and experiments, there can no longer be any reason 
why we should not have effective teaching of this special hygiene. Has it 
been of any permanent help to those who have received this instruction? 

Allow me to give you a few concrete cases — a boy in one of our suburban 
schools came under the influence of this teaching and applied his knowledge 
in his home, refusing toddy for his colds, and refusing to drink alcoholic 
liquors when the members of his family indulged, and he has carried those 
principles with him through the years and proved true to them in his uni- 
versity course and since. 

When they were celebrating the centennial of the founding of Wilkes-Barre 
a few years ago two thousand school children were congregated on a stand 
watching the parade. As the floats passed by they would sing patriotic 
songs and cheer lustily, but when the brewery floats came before them which 
were probably the most elaborate of the whole parade, the children allowed 
them to pass without a cheer; nor was a flag waved. 



no 

The City Superintendent of Public Schools of that city cited this as one of 
his reasons for his faith that the rising generation in the schools were 
being trained for the maintaining of good health and temperate living. 

When we have such men as Dr. David Starr Jordan, Mr. George Martin 
of the Board of Education of Massachusetts, Dr. Sims Woodhead of Cam- 
bridge, England, Dr. Arthur Holmes of the University of Pennsylvania and 
others of like standing cooperating with this department that we represent, 
it seems to me a sufficient proof in itself that such teaching is not only needed 
but should be welcomed everywhere by educators and professional people. 

May I quote Mr. Martin, of Massachusttes : " While education is taking on 
more and more an industrial phase, unless there goes along with the new 
form of effort constant, thorough, sympathetic instruction in the evils of 
alcohol, unless the generation going from the schools to the shops goes with 
sincere purpose to live a clean life, there is little hope that industrial con- 
ditions will be improved. The work of the schools to induce temperate 
and healthful living is infinitely more important than to secure skill in handi- 
craft." 

Human life and energy have increased in the three decades, we be- 
lieve, through the careful teaching in the schools of the scientific truth as it 
relates to the problem of how to live. The death-rate per i.ooo decreased 
from 30 in 1870 to less than 19 in 1905. 

Scientific experiment is convincing and far-reaching. 

Dr. Charles W. Eliot, former President of Harvard, said in 1908: "The 
recent progress of medical science, largely accomplished through animal 
experimentation, has satisfied me that even the moderate use of alcohol is 
objectionable; that the habitual use of alcohol in any form is lowering to the 
intellectual and nervous power." 

The children of the nation have been similarly convinced when they have 
been taught "to see light" in the same way. 

Our part in this great work is to bring the many valuable helps to the 
teaching force whenever and wherever we have the opportunity of so doing; 
we are not imposing any new burdens upon the teachers but endeavoring 
to lighten those they already have with the bringing of this truth to them 
through the medium of the various sane practical helps that we have at our 
command, and this department of scientific temperance instruction is only 
trying to help equip the teachers in a sympathetic way for the work that the 
law rightfully requires of them and that many of our normal schools fall 
short in giving. 

We would urge a definite course of instruction for those now studying in 
the Normals, and for those teachers already in the field suitable courses in our 
summer schools, such as the University of Pennsylvania has recently estab- 
lished and the University of Tennessee has successfully supported for several 
years and still others I will not designate. 



XII. 
EDUCATION FOR BETTER PARENTHOOD. 1 

By Thomas D. Wood, A.M., M.D., New York, Professor of Physical Education in Columbia 
University and College Physician, Teachers College. 

The teaching of hygiene in thorough and comprehensive manner 
should serve many important purposes in the education of young 
people — in helping to prepare them for the manifold phases of 
responsibility which life may bring to them. Hygiene instruc- 
tion, however, can further no more important interest; in fact, 
none so important as that which relates to the supreme privilege 
and obligation of life — namely, parenthood. And this obligation, 
impending even far off beyond the years in the life of the growing 
child, should be recognized by parent, by teacher and by all 
the adult guides of the young in a very practical way as a potential 
responsibility for which human beings are to be trained in a far- 
sighted and effective manner. 

We are fond of quoting Oliver Wendell Holmes — philosopher, 
wise physician and beloved author — as saying that the education 
of the child should begin two or three generations before he is 
born. Did he not anticipate in this significant paragraph the 
present-day conception of the principles underlying our ideas 
of eugenics, of education relating to the more direct and indirect 
obligations belonging to parenthood? 

The child is the most valuable object in the human world. 

Biologically speaking, the only reason for the existence of 
the adult of the species is the reproduction and care of the young. 
The most important business on earth is the bearing and rearing 
of children. And it is of all forms of business, in relation to its 
value to mankind, the most inadequately understood and the 
least well conducted. This is due in part to two causes: 

i. Men are most interested in, and devoted to, the enterprises 
which affect themselves, their own generation. 

2. For the most part they do best the tasks which appeal 
directly to the senses or whose results are quickly measurable 

1 Read at the Conference on the Conservation of School Children, Lehigh University, 
April 4, 1912. 



112 

in terms of money and in the immediate returns which money 
will buy. 

A high quality of parenthood, however, involves many essential 
ingredients and the most important of them lie well outside 
of the factors generally considered indispensable for the ordinary 
and most of the unusual pursuits of mankind, unless the rather 
sweeping assertion is made that intelligence and common sense 
are sufficient for all human occupations. 

Some of the comparatively rare ingredients which seem de- 
sirable for better parenthood may be briefly summarized as 
follows : 

i. For practical eugenics it is essential that the romantic, the 
affectional basis of marriage should be preserved, but the senti- 
mental and emotional elements should be supported and guided 
by intelligent appreciation of all the factors necessary for parent- 
hood which will protect the biologic values, as these are as im- 
portant in the human species as in any other. 

This view of life, in which the interests of the future determine 
present conduct, will modify the influences and attractive forces 
which draw men and women together for marriage and the insti- 
tution of the family. The dominance of this ideal will, uncon- 
sciously, even in the minds of those properly trained, tend to make 
those qualities, attributes and characteristics in each most at- 
tractive and desirable to the other which are most important 
in men and women, for parenthood, for the welfare of the future. 

In the mating of men and women, money, social position, 
worldly expediency, the conventional and fictitious values so 
influential in these days, will count for much less, while organic 
health and efficiency, character, unselfish devotion to high ideals, 
to the great world interests will count for far more. In this 
obedience to ideals so far-sighted, romantic love will not be 
lost in any way, as some seem to fear. Men and women will 
not choose one another in cold blood simply because intelligence 
and reason point the way, but human sentiment and every roman- 
tic quality will be enhanced when permanent and future interests 
are furthered by a saner and finer human choice. Marriage in 
many of its most important aspects can not be controlled by 



"3 

law (except in the case of the dependent classes) or by a hard 
impersonal science, but it may be controlled to immense human 
advantage through the ennobled and rationalized sentiments 
of men and women trained from childhood to justly estimate, 
almost instinctively and automatically, the vital issues of life. 

2. Parenthood requires that the child, the young of the species, 
shall not only be provided with the conditions for physical growth, 
health and strength; not only with the habits of industry and 
skill necessary for the maintenance of life and for acquirement 
of material resources conditioning intellectual and esthetic 
satisfaction, but also with the standards of thought and con- 
duct; with the controlling motives for action which will consti- 
tute the best preliminary training during infancy, childhood 
and youth for potential parenthood and all that it includes. 

When human beings and families rationally subordinate their 
own interests as perfectly to the welfare of future generations 
as do animals under the control of instinct the world will have 
a more enduring type of family life, a more perfect type of parent- 
craft, than exists at present. This can be accomplished only 
by the development of controlling ideals which are supported 
not alone by reason and intelligence but by ethical impulse and 
religious motive. This larger altruism which protects the perma- 
nent interests of the future against the more temporary values 
of the present must be of the heart as much as of the head. 

3. Parenthood is the provision for the perpetuation of the 
species — of the race. The life of the animal is controlled by 
instinct in the interests of the generations yet unborn. 

In the scale of relative values the child is more important 
than the parent, but future generations are again more important 
than the child. Under our present conditions even when parents 
are devoted to their children, the child is too often considered 
as the end of their affectionate care, is frequently more or less 
spoiled and the true process of human progress is interrupted. 
Children can not receive too much thought and care if these are 
wisely directed, but they can and often do have too much mis- 
directed attention. How often the child is subordinated to the 
parents' pleasure and pride. He must show off his accomplish- 



ii4 

ments before friends and strangers. He is perhaps over-stimulated 
with excitement when he should be simply vegetating. He 
or she is often made the burden of "conspicuous waste;" to dis- 
play the wealth and indicate the social position of his or her 
parents, in wearing garments and decorations which interfere 
with the most wholesome life and activities. Often again the 
child is over-fed or rather given what he pleads for, whether 
good for him or not, and this may be while he is really suffering 
from deficient nutrition. Frequently the child is overworked 
or at least forced beyond healthful limits in school; drawn too 
early into social life; made to conform to conventional stand- 
ards in education and society and this either to gratify his own 
precocious desires or to satisfy the irrational ambition of teachers 
and parents. All of these phases of developing life are but 
means to a greater end in the future even of the individual. 
The child should not be trained for mere personal attainment 
but for maturity, with reference to the power he will exert later, 
the influence which he will have in his own life and through 
this on those who come after. 

The home should be considered the place where are to be 
developed and conveyed the precious qualities which are so 
vital to the continuity of the race and the progress of human 
society and civilization. 

A higher type of parenthood will possess in itself and develop 
in the child a long distance view, a projected vision, an imagina- 
tion which will conserve and foster future values more success- 
fully. 

How much can education contribute to better parenthood? 
Very little, if it involves simply informative instruction of the 
traditional type, the imparting of facts relating to reproduction, 
to heredity, to parenthood. On the other hand, education may 
contribute much if it be broad and comprehensive, taking 
account of the psychic, social and moral as well as the physical 
nature of the young; striving to inculcate habits of thought 
and action sufficient for the present and adequate for the future 
needs of the child; to inspire ideals and establish standards of 



"5 

life which shall provide for racial and future as well as present 
and personal needs and obligations. 

The phase of human teaching, which is, last of all and most 
reluctantly, being recognized as essential, appropriate and possi- 
ble for education and for hygiene ; for life preparation of the human 
individual, is that which relates to the perpetuation of life, to 
the reproduction of the species, to the thought and conduct 
which is directly and indirectly associated with this phase, and 
responsibility of life. 

In an analysis of reasons for delay in the development of 
this department of education, the following suggest themselves: 

i. It has been assumed, until recently, by most people, and 
is still believed by many, that an innocence dependent upon 
comparative ignorance of reproduction is desirable up to 
maturity. 

This, in part, was due to the general belief that the repro- 
ductive instinct and its expression and influence in human life 
were, in the nature of things, not adapted to rational understand- 
ing, and direct instruction and guidance . In fact, much of the 
attempted teaching in this field has consisted in the efforts to 
discourage or suppress inquiry or thought on subjects relating 
to sex, rather than to encourage suitable, wholesome understand- 
ing and control of knowledge and impulses. 

2. There has been lacking a definite body of knowledge and 
opinion regarding the biologic, hygienic, psychologic, sociologic 
and ethical aspects of sex sufficient for satisfactory education 
in this field. 

Upon no subject of vital importance to the welfare of young 
people are parents, teachers, physicians and adults in positions 
of responsibility, so ignorant and lacking in unanimity of knowledge 
and opinion as with regard to sex in its direct and indirect bearings 
on the life of the young. 

3. The atmosphere of human life, in respect to sex and re- 
production has been so often clouded; the stream of human 
thought, of memory and conduct has been, and is so often, made 
turbid by various degrees of error, that many really good people 
fail to fulfil their obligations of instruction and guidance of 



n6 

their own children or of the children of others. Again, not a 
few parents and teachers, through lack of appropriate training 
in youth, or because of temperamental limitations, are so con- 
stituted that it seems almost impossible for them to teach and 
guide with frankness and tact their own children. 

For the protection and help of their own children, and of young 
people generally, from error directly or indirectly related to sex, 
they depend upon the carrying over of facts and principles of 
science and morals in a way which will insure sufficient wisdom 
and safety for the young at various ages. 

Human experience has abundantly proven that dependence 
upon such an indirect and roundabout process of reasoning, 
and of guidance for human conduct is illogical and ineffective. 

Certain positive reasons present themselves in support of the 
proposition that: Appropriate education with reference to re- 
production and parenthood is vitally necessary in the develop- 
ment of every young person. 

i. The human individual can find himself in relation to knowl- 
edge, impulse and responsibilities of sex, at earlier or later stages, 
with reference to himself or others, only by the instruction and 
influence of those who shall be adequate to supply the need at 
each stage of experience. 

Instinct and intuition are not sufficient for thought, judgment 
and conduct, which will be satisfactory in this sphere. While 
conscientious application of general, moral and religious principles 
to the sex life may save many from flagrant error, still this form 
of protection is very uncertain, and altogether insufficient for 
the more positive needs of human life. 

2. For the complete development of mind, soul, character, 
and personality each child absolutely needs, and hence is entitled 
to, a normally growing body of knowledge of the great facts 
and principles of reproduction; of the perpetuation of life; which 
is involved in the individual increase of consciousness and is 
related to the developing sense of personal, social, parental, 
and racial obligation. Parkinson, in his illuminating article 
on sex education in the Educational Review of January, 191 1, 
has made a valuable contribution to the literature in this 



ii7 

field with his clear and stimulating exposition of the bene- 
ficial effects of the right kind of sex education in the gradual 
upbuilding in the young of mind and personality. 

3. The third striking reason for sex instruction is to safeguard 
the young, so far as teaching may accomplish this, against the 
errors and disasters which come through the violations of the 
laws of sex hygiene. 

The prevention of sex error, perversion, immorality, and disease, 
while important as an argument for sex education, and as a motive 
for sexual morality, has often been made too prominent in the 
discussion of this subject. The prevalence, character and sig- 
nificance of venereal diseases in the world involve facts of awesome 
import in relation to the health and morality of the individual, 
family, community and nation. With these vital problems, 
all types of repsonsive agencies must seriously and constructively 
deal. 

The fear of disease, however, is not the highest nor most effective 
type of incentive to decent and fine living. It should be em- 
ployed with all force for those who cannot be effectively appealed 
to on a higher plane, but the finer considerations and motives 
should be employed first, and to the full measure whenever there 
is a reasonable chance for them. 

If we assume that sex instruction of the right kind is necessary 
for every child, then the question arises : When, how and by whom 
shall such instruction be given? 

Without attempt at comprehensive and logical development 
of this phase of the subject, certain opinions are presented in 
somewhat categorical fashion for consideration. 

The most natural and logical teacher of sex and parenthood 
to the child is the parent. For the parent, wise and sufficient 
to opportunity and needs, this may be even more a privilege 
than a duty. Parents should be urged and helped in every possi- 
ble way to fulfil, as far as may be possible, their obligation in 
this field of teaching to their own children. 

If parents fail in this duty to their children; if they cannot, 
or will not, or for any reason whatsoever, do not help their own 
sons and daughters in this essential aspect of preparation for 



nS 

life, then it is most important that help should be given by person 
or persons old enough, wise enough, and situated in such a re- 
lation to the child that, in view of all the circumstances, such 
instruction, such guidance, such help, may reasonably and 
suitably be given. Shall it be admitted that, in a civilized nation, 
in a Christian country, in an intelligent community, there may 
exist a single child who will fail to receive the needed teaching 
and guidance related to the wonderful, the essential truths and 
principles; the laws of sex, of reproduction, of parenthood? 

It is certain that multitudes of children are growing up without 
an} r suitable teaching in this field. A very small percentage 
of the children of this generation is getting, or will get, any 
adequate instruction and guidance in this department of life. 

The children of the rich are, save for certain conventional 
and temporary elements of protection, no better off than the chil- 
dren of the poor. Orphans sometimes are more helped than 
many children surrounded in parental homes by luxury and 
negligence. 

It is not proposed here to discuss the problem of class-room 
or group instruction with reference to direct human sex teaching 
in the public school beyond the expression of the writer's con- 
viction that such instruction cannot be given until : (a) enlightened 
public opinion recognizes sufficiently the necessity for such in- 
struction, and exhibits confidence in the ability of the teachers 
to give the instruction needed; (b) teachers are intelligent, wise 
and tactful enough to give such instruction and guidance success- 
fully. Comparatively few teachers to-day are capable of meeting 
the obligations involved in sex education. 

Such instruction should be given in universities, in colleges, 
in normal, and in private schools. It is very important that 
parents, teachers, physicians, nurses, social workers and all serious 
adults should in all possible ways be informed upon this subject, 
and make themselves capable of advising and guiding young 
people individually, and thus the way may gradually be prepared 
for the more complete and satisfactory teaching in this field 
which must come in the not distant future. 

With reference to the individual teaching of the child wherever 



ii 9 

and whenever this may be sensibly possible, some fundamental 
considerations seem important. 

The average normal or typical child up to the beginning of 
adolescence, at least, is unconscious of sex feeling or impulse. 
The curiosity of such a child regarding reproduction repre- 
sents the same kind of natural intellectual inquiry which the 
child might feel or express regarding any interesting phenomena, 
unless by the unfortunate attitude of elders and companions, 
the child is made conscious of some peculiar quality or interest 
attaching to this class of subjects. 

There are, of course, some children, who, before they reach 
their teens, for one reason or another, have become precocious 
in relation to sex feeling or habit. These should be helped 
as wisely as possible according to individual needs. It is most 
important, however, that the simple, natural, and relatively 
unconscious attitude of the typical child should be preserved, 
not by withholding knowledge, but by giving all the instruction 
needed in the most satisfactory manner. 

The child, up to adolescence, will be best taught first by the 
carrying over of the applications from nature study, and from 
the study of life in general, and, second, by the satisfying answers 
to the freely asked questions of the child as they occur. The 
possible exceptions to the above might be the simple directions 
to be given to the child regarding the routine care of the body 
when the age of self -care is reached. 

For the young child, however, the problem is more psychologic 
than hygienic or moral, and no problem in education requires 
keener psychologic insight, or finer pedagogic skill than to know 
how the individual child should have the simple sex questions 
answered according to nature, temperament, stage of mental 
development and the rest. It is better not to put any of the 
sex books into the hands of a child, but the parent and the teacher 
should be familiar with the best literature in this line, and be 
able to give the instruction in a direct and satisfactory way. 

The basis of successful sex teaching is companionship and 
confidence between the child and the parent, or the person who 
stands in loco parentis in relation to this phase of instruction. 



120 

The child should be most inclined to ask for information where 
this may most safely and wisely be given. 

This need of the child for wise and tactful guidance exists 
up to maturity, and complete education involves for each young 
person the help of a perfectly qualified and sufficiently interested 
person during the years of growth and groping through the mazes 
of human development. 

When class or group instruction is given to adolescents of 
either sex, it is most important that the primary emphasis should 
not be given to sexual anatomy or physiology, which may be 
unnecessary or confusing, or for some undesirably suggestive, 
but rather to the presentation of facts and values, biologic, hy- 
gienic, sociologic, ethical and economic, which will inspire youth 
to wholesome thought and conduct and warn them against error 
and harm to themselves or others. The welfare of those who 
are now, or may be later, dependent upon them, will restrain 
many young people from thoughtless or injurious conduct when 
consideration for their own safety would not act as an effective 
deterrent. More important than the knowledge of sex hygiene, 
then, are the motives, which at different stages of development, 
and for different types of young people, will control thought 
and action as effectively as possible. 

In this connection may be appreciated the significance of 
title of Dr. Cabot's paper on "Sex Education," which he calls 
"The Consecration of the Affections." The devotion of a child 
to sympathetic parent or friend ; the devotion of youth to a human 
ideal; the devotion of a young man to the imagined or actual 
woman whom he hopes to marry will often be the most compelling 
influence to hold the individual to a worthy standard of living. 



XIII. 

EDUCATION FOR PARENTHOOD. 1 

By Helen C. Putnam, A.B., M.D., Providence. 

We are facing certain facts: One is that parenthood does 
not make wise parents, for some fathers and even some mothers 
deliberately teach their children vice; more, by their conversa- 
tion and acts, carelessly teach evil; many more, while perhaps 
guarding their own, will, in order to make money, degrade the 
children of other parents by employment and wages, by housing 
conditions, by entertainments and reading matter and pictures, 
by saloons and other details of city management; very many 
more parents neglect their children through ignorance, or in 
other occupations and pleasures. A very large part of modern 
social effort is struggling to undo the mistakes of parents. 

We are, too, facing the facts that manhood does not always 
make a wise citizen, nor womanhood always an unwise citizen; 
that political elections do not make wise government nor wise 
school officials. Right education is the remedy for unwise parents 
and citizens of either sex; for unwise officials in state house, 
city hall, and school department. The crucial education is 
that for parenthood. Parenthood may become the nearest to 
Godhood. 

The Creator has established certain laws for parenthood. 
Their violation even ignorantly injures future generations, 
burdening society and hindering higher civilization. Our first 
duty is to search out his laws, and this is done by expert students 
of his handiwork — man and the not-man. We call them scien- 
tists, whether they study mind, or matter, or social relations. 

Our second duty is to prepare in this scientific knowledge 
of parenthood teachers of children — the potential parents; for 
the foundations of good parenthood must be laid before the event ; 
after is too late to undo the errors committed and duties omitted 
in childhood and youth. Neither can we have marriages accord- 
ing to the laws of God until standards are so formed that only 

1 Read in abstract at the Conference on the Conservation of School Children, Lehigh 
University, April 4, 1912. 



a wholesome person and character attracts love — the consum- 
mation of the law. The affections once engaged, even if sin- 
ning against the laws of parenthood, can be diverted only in 
exceptional cases and with suffering. 

This preparation of teachers of potential parents has been 
developing during the last twenty years in certain places along 
definite lines, until paths well blazed by successful experimenta- 
tion indicate where our efforts should concentrate. Preparing 
for wise parenthood is as definite a process as training for nursing, 
or for running a bank, or for building a bridge. As schools 
for nurses, one of the most beneficent undertakings of the nine- 
teenth century, were initiated by medical women in their own 
hospital, so this training for parenthood was launched in the 
public schools of Boston by the intelligent persistence of college 
women, and against political indifference or incapacity or opposi- 
tion is winning its way in every state. 

Such courses for teachers are found in twenty or more universi- 
ties and academic colleges, in twice as many special institutions 
and high schools, and in practically every agricultural college, 
for the United States Department of Agriculture has been their 
strong supporter. The ages of pupils range from seventeen to 
twenty-five or thirty. They may teach,' and they may marry. 
These courses have minor variations, but the brief description 
of one will give a fair idea of the trend of all. 

This course 1 takes the larger part of pupils' time for four 
years, the remaining being given to the usual studies — language, 
literature, history. The wise locating, planning, and building 
of a house, its wise care, the care and feeding of a family depend 
fundamentally on understanding certain laws of chemistry, 
physics, and living things (biology), and on skill in the arts of 
applying them to the duties of parents. These sciences are taught, 
not as we find them ordinarily in men's curricula, but as they 
directly concern healthfulness of premises, clothing and habits, 
wholesomeness of food, and, finally, the creation developed out 
of these factors and habits, character and social relations. 

The central thought on which these four years of work is focused 
is: "Improving the individual so that future generations may 

1 Department of Home Economics at the University of Wisconsin. 



123 

attain a higher level than those preceding them." Education 
before this has stopped with more or less of improving the indi- 
vidual so that he may win "success," or "happiness," or wealth. 
This definitely holds up an ideal of responsibility that is infinite 
— future generations. 

A summary of their study of social relations will be useful. 
It comes after two and a half years in chemistry, physics, biology, 
bacteriology, physiology, and household management. The 
development of the infant before birth from the single cell is 
first discussed, and as they have seen these beginnings many 
times in plant and animal life in their biologic laboratory, it is 
a simple matter to adapt that knowledge to human life. The 
discussion of heredity, of which they have already tested certain 
facts in their biology, takes up Mendelian laws of inheritance 
of inherent characteristics, the inheritance of acquired charac- 
teristics, the effects on germ plasm of alcoholism, syphilis, drug 
habits. They learn the fact that drunkards, insane, feeble- 
minded, habitual criminals, and sexually depraved men and 
women usually have children with defective nervous systems, 
and usually breed their kind. They learn the real significance 
of "good stock" on the father's side and on the mother's. 

Teachers with this knowledge can do much, indirectly and 
directly, in mothers' and parents' clubs and with children to de- 
velop through the country right ideas of marriage to replace 
the unwholesome ones now so common among young people 
and among their parents, who should know and teach their children 
better. 

There is a far-reaching significance in their enumeration of 
syphilis and gonococcus infection (not "gonorrhoea," one of 
its manifestations) among ordinary contagious diseases, and 
in their study of these statistics as well as the others in govern- 
ment and scientific reports, and their relation to the home; for 
they are not less than five times as prevalent as tuberculosis 
and all other contagions together, and they injure wives and 
children to an extent not possible to estimate. They are the 
cause of many deaths before birth (characteristic of syphilis) ; 
of the death, degeneracy, blindness of many infants in the first 
years of life; of many childless families and one-child families 



124 

(a peculiarity of gonococcus infection) ; of the invalidism, surgical 
mutilation, and death of many wives; of much insanity, rheuma- 
tism, heart disease, and other physical and mental incapacity; 
of much divorce, unhappiness, crime; of expenditure of large 
public and private funds and effort on misfortunes that can and 
should be prevented. They have, through slow processes, 
exterminated ancient nations and modern communities. If 
they increase through the next quarter century at the rate of 
the last, it would seem as if this nation, too, must decline. In 
my own professional experience, as in that of other physicians, 
the fate of married sister or friend has prevented — is preventing — 
marriages. 1 

The students see logically that control of these contagions 
must be the same as control of small-pox, scarlet fever, and any 
other of the several that we have almost eliminated — every case 
must be reported to the board of health. That this so evident 
first step is not taken is due to the fact that boards of health, 
who are charged with administration of health laws, do not en- 
force the law requiring this done; that in the majority of states 
these laws have still to be enacted; that the great majority of 
physicians will not report these cases because they are almost 
always connected with illegal sex relations of men which they 
wish concealed; and that city governments, through their courts 
and police, permit these dangerous men to pass freely about 
in the community and into the homes where prostitutes never 
go, because of the established idea that men may lead irregular 
lives not permitted women — the so-called "double standard of 
morals." 

Education for parenthood necessarily brings with it the in- 
sistence that government shall protect marriage from these 
contagions and their inseparable evils; and as government does 
not do so, never has been known to do so, possibly never can do 
so as the great majority of men claim, women in various countries 
in increasing numbers, and with the cooperation of many of the 

1 For the above and additional facts see Chapters XV, XVI, XVII, of "Medical Gyne- 
cology," by Dr. H. A. Kelly, of the Johns Hopkins University; "Social Diseases and Mar- 
riage" by Dr. Prince A. Morrow (Lee Brothers & Co.); Educational Pamphlet No. 3, 
issued by the American Society of Sanitary and Moral Prophylaxis, 29 West 42nd 
Street, New York (a reprint of one of Dr. Morrow's most important chapters). 



125 

best men (but invariably fought by saloon, gambling, and other 
vicious elements), are securing the political right to protect 
their own and the children's lives according to their duty to the 
laws of God. There is no doubt in the minds of keen students of 
social relations that political dominance of sex is wholly an evil, 
and to both sexes; that the only right dominance is wisdom, 
of which education and experience are giving women full share 
with men. Civil law made by men not based on biologic law 
which women are learning ends in disaster. 

The wise intelligence of mothers, of professional women in 
the ministry, in law, in medicine, in sociology, and in education; 
laboring women with their sense of wronging their children when 
the}' go out from the home to earn their food and roof; and the 
other mothers who see their dearest, without legal protection 
or redress, contaminated, body and soul, out of the under- world 
whose pollution reaches all classes; these are concentrating on 
the demand, and are winning it. It is an indispensable step 
toward the establishment of right sex relations. 

After this study of heredity comes study of physical and mental 
development of child and adolescent; the influence of city life 
and country life on development, with school statistics of the 
rates of growth of boys and of girls ; the kind of education adapted 
to different kinds of children; infant mortality — the effect on it 
of women's work outside the home, and of different kinds of 
occupations of mothers before the child is born; governmental 
and social efforts to reduce infant mortality; the pension system 
for mothers, paying a small sum enabling them to stay at home 
and nurse their babies, thus saving citizens to the state, as govern- 
ments have hitherto pensioned soldiers ; the effects of institutional 
care of babies and children on death-rate and on development; 
the cause of reduced birth rates, and the duty of the educated 
in the preservation of the race; children in industry, and its 
legislation; the housing problem; child psychology; children's 
vices; education of the will; a study of nervous states and their 
hygiene. 1 

1 For fuller account of this and other courses see reports of Education Section, 
1910 and 1911, American Association for Study and Prevention of Infant Mortality. Ad- 
dress 1211 Cathedral Street, Baltimore. Each, 20 cents. 



126 

Such topics in some schools are, so far as practicable, made 
vital by cooperation with neighboring nurseries, hospitals, or 
other institutions; and there are of course children's classes 
in the practice school wherever teachers are trained. One 
has to regret that there is not yet a course for men complementary 
to this in some of its details. Many of the universities and col- 
leges giving these courses have in the winter extension courses 
of a week or more, which are taken by thousands of farmers' 
wives and other women. In elementary schools competent 
teachers have organized many hundred classes of mothers and 
of parents, where study of and home cooperation in the education 
of their children is steadily being developed. 

What some teachers are doing with children themselves can 
best be indicated by a few typical instances. Teachers of the 
youngest grade, in their study of flowers, birds, and other animals, 
speak of mother flower or animal, father and baby flowers and 
animals, tracing likenesses between parents and young, comparing 
their ways with people's ways, establishing thus indirectly the 
consciousness, or, better, sub-consciousness that every life is 
from fathers and mothers, from eggs or from the mother's body, 
that there are fertilized and unfertilized seeds, that heredity 
and environment are factors in life — not using, however, these 
polysyllables. 

For children a little older, nine to eleven, a teacher who had 
studied biology began in the seventh grade a "continued story," 
"The Story of the World We Live In." The "first chapter" 
was brilliant chemical experiments illustrating gases, vapors, 
condensations into liquids and solids, some of the curious proper- 
ties of water. In the following lessons they saw simplest plant 
life, yeast cells, through a microscope, and learned how they 
multiplied. The)^ took for their text: "The two objects of every 
living thing are to perfect itself and to reproduce itself." This 
text was repeated, and formed the line of study for every plant 
through the year — how it grew and how it multiplied. The 
next year, in the last grammar grade, the continued story used 
the same text for every animal studied, how it grew, perfecting 
itself, and how it multiplied, giving as much attention to repro- 
duction (which instructors usually omit) as to other functions. 



127 

It is to be remembered that the instructor was a student of biology, 
and the teaching was from this viewpoint. 

In answer to my question, 'Do you think you have taught 
anything of clean living?" she replied emphaticly, "I am sure 
I have. There were two boys two or three years older than the 
others. They were precocious and unclean-minded. It could 
be seen in their faces in the beginning. I had no private talk 
with them, but at certain points I took special pains to have them 
understand. Before the course was over there was a complete 
mental revolution, and moral, too, I know from their manner. 
They are clean, good boys now, and twice as bright." 

There is a grammar school in the tenderloin district of a large 
city. The sights and sounds of the district educate the children 
more hours in the year than the school. The innocently-ex- 
pressed ambition of the little girls was to be a "fancy lady," 
whose idleness and gay dresses were more attractive than their 
toiling mothers' lives. The little boys, too, admired the "fancy 
ladies." The teachers, startled by the children's standards 
and unconscious vulgarity in many ways, begged the superin- 
tendent of schools to have a physician talk to them. He did not 
say, as some: "Let it alone. You will only set them to talking 
and make matters worse;" nor as another said: "You are a 
dirty-minded woman yourself or you wouldn't see such things." 
He asked a medical woman who had been a successful teacher 
before studying medicine to give a talk to the girls ; and he asked 
a medical man to do it for the boys. Each, ignorant of the other's 
action, refused, saying that one talk from a stranger would 
do harm, not being enough to cover so much. The medical 
woman offered to give twelve or fifteen talks, and include what 
was wanted. When she had so discussed general health habits 
that she had interested them and changed their mental attitude 
toward their bodies and toward life in some ways, she then safely 
discussed sex and its duties. After a few weeks of this course, 
the boys sent a petition to the principal: "Can't a doctor give 
us talks like the girls?" The medical man then gave three talks 
on general hygiene, and finally one on sex, beginning with laws 
and phenomena in plants and animals, so placing human law 
in relation to universal law. 



128 

The results of this experiment were highly satisfactory. Con- 
duct, conversation, and ideals were for the time changed among 
these unfortunately surrounded children, but it would be a miracle 
if these few hours could undo the constant influence of a "red 
light" neighborhood — environment such as every large city per- 
mits for some of its children, centrally located for the sake of 
business, yielding extra high rentals to people of large means 
who own such real estate, and are not infrequently found among 
subscribers to philanthropies and to churches. Nearly every 
genuine attempt to break up such resorts is halted by the dis- 
covery at the tax assessor's office that the landlord or landlady 
is a person of social consideration. These reason: "My property 
is my own to do with as I please. If they pay their rent, I can't 
meddle with their morals" — the philosophy that a distinguished 
student of immoral women tells me is theirs, "My body is my 
own to do with as I please. I can earn more money this way. 
I will not work in a factory." Prostitution is largely an economic 
problem with several sides. These school authorities consider 
this as the handling of an emergency, not as what should be 
done regularly. They are developing systematic instruction 
in nature study and hygiene as rapidly as capable instructors 
can be found. 1 

In a large city is a teacher of biology for children from twelve 
to sixteen, who year after year for nine years, has taught in her 
classes of both boys and girls how every plant and animal they 
studied not only grew, but how it multiplied. She says enough, 
but no more than enough, to set them almost unconsciously to 
reasoning from these to laws of human life. They actually demon- 
strate principles of heredity while cross-fertilizing flowers, and of 
environment in other experiments. This instructor and other 
biologists are increasingly including the discussion of contagions 
which are due to minute vegetable and animal organisms, "germs ;" 
and in the list of commonest contagious diseases enumerate syphilis 
and gonococcus infection along with the others, perhaps giving 
a few facts and statistics concerning each, without discriminating 

1 Dr. Zenner gives a full account of this and his further personal experience in talking 
to pupils in a little book: "Education in Sexual Physiology and Hygiene" (The Robert 
Clarke Company, Cincinnati). He makes no attempt to cover the subject, but contrib- 
utes what we specially need just now, "clinical evidence." 



129 

against these in particular. This is the honest and clean-minded 
course. 

In the last few years former pupils who have become parents, 
and others have told her gratefully what an illumination and help 
this knowledge had been to them. She says, as others also, 
that quite without her anticipating it in the beginning, the under- 
current of vulgar talk among the children spontaneously ceases 
as they advance in the study. The normal curiosity about 
sex and new life, as much a part of human nature as is love for 
pleasure, is directed in open channels where it can be enlightened 
healthfully, without defilement. A well-known educator of 
large experience once said to me, reflectively passing the problem 
through his mind, "I know no man in the schools of my city 
and but few women that I would be willing to have talk to my 
boy and girl on sex matters." "Would you be willing to have 
them take a sensible course in elementary biology?" He replied 
promptly: "I not only would be willing, but glad to have that." 

These teachings, so rapidly outlined, agree in certain very 
important points, and demonstrate certain very important 
principles : 

i. Not all teachers should undertake this, but only those 
prepared to teach the elementary science of living things, and 
with understanding of elementary sociology. Such do little 
with books or talks. Pupils see and handle plants and animals, 
watching life processes with minds that are guided to search jot- 
law. 

2. Direct sex instruction in class is not given even in emergency 
until there is a well-laid groundwork in the renewal of life in 
all nature; a scientific setting or background, with a scientific 
vocabulary, that eliminates the vulgar attitude toward facts 
of sex inevitable when they stand alone. 

We have made the deadening mistake of omitting from educa- 
tion all direction of the duty of passing on the torch of life entrusted 
to each for a few years. Education has been limited to self- 
preservation. Our sins of omission cannot be undone. The 
sorrow and suffering have been and left their blight. 

We are in some danger, in our haste to get wise, of going to 



130 

the other extreme, and over-emphasizing what is called "sex 
hygiene." This can hardly do more harm than altogether 
omitting it; but agitation for "instruction in sex hygiene," 
and for societies of "sex hygiene" seem over-emphasis. What 
we should agitate for and have organized effort to secure are: 

i. Compulsory control of syphilis and gonococcus infection 
by boards of health. A very few societies with this object exist, 
working as definitely as do our many anti-tuberculosis societies 
on their problem. 

It seems desirable to urge at this point that those physicians 
who use the unscientific names "venereal" or "shameful" or 
"sexual diseases" hinder progress in prevention very greatly. 
Many of the laity, especially educated women, are pursuing the 
correct method — declining to adopt or to otherwise encourage 
the obnoxious terms; but, instead, using the technical names, 
syphilis and gonococcus infection, in which there is no suggestion 
of evil, although some of the victims like some of the victims 
of diphtheria may be evil. Or they use the collective term 
social diseases, being mindful of the fact that tuberculosis, ty- 
phoid and others are also social diseases, diseases encouraged by 
our present social practices. 

Some of the reasons for avoiding a nomenclature suggestive 
of immorality are : (a) Syphilis and gonococcus infection may be 
acquired without sexual irregularities as, for example, from the 
common cup or towel, from kissing, handshaking, or other inno- 
cent contact, or by marriage or by birth — all these being also agen- 
cies for communicating other contagion. Neither affects the 
reproductive system exclusively, both being systemic diseases 
attacking brain or other parts of the nervous system, bones, 
eyes, thoracic and abdominal viscera, and resembling other 
systemic diseases enough to cause errors in diagnosis, syphilis 
being occasionally mistaken for tuberculosis in its early stages, 
or for malaria; and both passing under other commonly used 
names (for example, "heart disease," "rheumatism"), neither 
being found, with rare exceptions, among causes of death recorded 
by health departments, in spite of their general prevalence. 

(b) The terms are obstructive, for, until we cease to stigmatize 



i3i 

patients (often unjustly as well as justly) we cannot secure 
enforcement of laws sufficiently effective to control the pale 
spirochete and gonococcus as we control other specific micro- 
organisms. 

2. Efficient teaching of home-making ("domestic science," 
"home economics") , especially in "continuation schools" or classes 
for our twenty million young people between sixteen and twenty- 
four years of age, now in no schools. These are strategic years, 
when home-making instincts are waking. 1 

3. Sensible teaching of the science of living things ("nature 
study," "school gardening," botany, zoology, elementary biology) 
as a compulsory study in elementary and secondary schools. 

With these must be school environment and practices that 
grow healthier children to become healthy parents, and that 
are essential factors in "teaching hygiene. ' ' Our schools encourage 
tuberculosis, nervous disorders, and some other ills whose pre- 
vention is outdoor air and more occupations that increase the 
circulation, which means stronger hearts, lungs, and other vital 
organs. If home-making, gardening, and industrial training 
are wisely developed, they will improve the health of parents 
as well as their efficiency. 

Schools should aim to create a national consciousness, a sub- 
consciousness developing through childhood, that life is a trust 
received from many who have gone before, to be guarded and 
bettered in one's turn, and passed along to many after — a simple 
and easily demonstrable supplement to the more vague idea of 
God, stimulating an early sense of responsibility that is to moral 
life what physical exercise is to bodily life. 2 

1 See Continuation Schools, Education Section, American Society for Study and Pre- 
vention of Infant Mortality. 

2 Further discussion of school work is in Educational Pamphlet No. 2, "For Teachers," 
published by the American Society of Sanitary and Moral Prophylaxis, previously men- 
tioned. Important popular discussions of education for parenthood are in the Report 
of Conference on Prevention of Infant Mortality, 1909, American Academy of Medicine, 
Easton, Penn. ; also in the Reports of the Association for Study and Prevention of Infant 
Mortality mentioned in previous foot-note. 



XIV. 
INDIRECT METHODS OF TEACHING HYGIENE. 1 

By C. B. Ehinger, M.D., West Chester, Pa., Physical Director State Normal School. 

In going over the subject assigned me, I find some difficulty 
in determining exactly what constitutes indirect methods. 

There can scarcely be any doubt on this point under some 
headings, but it seems quite evident that what would be considered 
indirect methods by one would seem essentially direct by another. 
I take it, however, that the question of the implied motive of 
the instructor and the conscious attitude of the pupil must, 
in the end, determine this point. 

All those who have had experience in teaching hygiene to 
young people will have noted the indifference and even contempt 
which they often manifest towards the most painstaking direct 
efforts at instruction, which fact would seem to justify a more 
frequent use of indirect methods; and certainly the success 
sometimes achieved in presenting this subject indirectly, warrants 
us in more frequently resorting to it. 

The apparent apathy of young people to matters pertaining 
to their health is to a certain extent natural and proper and must 
not always be taken as an evidence of perversity or inherent an- 
tipathy to the whole subject. 

To the artless and inexperienced mind of youth the question 
of disease or physical abnormality has no legitimate place in the 
scheme of life. Doubtless some of the dislike of the youthful 
mind for this subject is owing to its improper presentation and 
more especially to the enlargement upon the negative side, to 
undue emphasis on diseased processes, the dark side of the picture 
being overdrawn and kept in the foreground. The fact that 
indirect methods should be suggested as a topic for discussion 
at this Conference is evidence that direct methods have sometimes 
failed of their purpose. 

I will touch mainly upon phases of teaching which are the 

1 Read at the Conference on the Conservation of School Children, Lehigh University, 
April 4, 1912. 



133 

outcome of my work and experience as a physical director, and 
I shall emphasize more particularly the possibilities in the recrea- 
tional and competitive fields. 

The opportunities of the physical director and athletic trainer 
to press home hygienic truths in a palatable form are indeed 
great. 

This phase of the subject naturally raises at once the question 
as to the desirability of the physical director teaching hygiene 
by the direct or usual methods. The matter has been discussed 
more or less for a number of years in physical education circles, 
and while the status of the physical director on this point is not 
definitely settled by educational authorities generally, I think 
I may say with confidence that the consensus of opinion in our 
own field is unquestionably in favor of his assuming this branch 
as a coordinate part of his work. There can scarcely, however, 
be any question as to the desirability of his teaching hygiene 
by indirect methods in the course of the duties now assigned 
to him. 

It seems quite pertinent to the subject in hand to devote a 
moment to the relation of physical training and athletics to hygiene 
in general. No other instructor has so many and such unique 
opportunities in this field as the physical director, trainer and 
coach. His relation to students and our youth generally affords 
unsurpassed advantages' to make effective appeals for their 
physical betterment; not even the medical adviser knows so 
well their physical needs, since the information obtained through 
physical examinations and activities in the gymnasium and on 
the field, give him the key to both his pupils' interests and needs. 

The interest and value of athletics is due to the fact that they 
are the outgrowth of fundamental instincts and not the result, 
nor merely incidental to civilization or formal education; they 
are the expression of the natural play tendencies of all youths. 
Athletics are but the play instincts more matured. Most, if 
not all, of the great evils so much deplored in athletic activities 
have arisen because we have failed to recognize that these are 
not only the legitimate but one of the most important of the edu- 
cational processes, and success in remedying these mistakes 



134 

will depend on the recognition of their true end and aim, and 
their relation to education. 

Dr. Wm. W. Hastings has well said that "physical education 
as a science is a department of hygiene," and it must be obvious 
to every intelligent person that the emphasis of physical education 
should make for general health and organic vigor. 

The childish interest in play, the youthful addiction to sport, 
and the adult appreciation of the value of health have nowhere 
such common meeting ground as in recreational and competitive 
activities, and it is through such avenues that we should be 
able to make our teaching of hygiene effective, to impart the 
much needed knowledge in a way that is not only interesting 
but highly pleasurable. This is the natural process — education 
through play, the application of play instincts to a maturer 
field. 

It is, indeed, encouraging to note that the hygienic aspects 
of physical training and athletics are becoming more evident 
and are being increasingly emphasized. The fact that athletic 
success depends largely upon physical fitness must be the keynote 
of hygienic teaching among young people, and this will be both 
the opportunity and the means by which the physical director 
shall meet the needs of his charges. That much, and perhaps 
most, of the best teaching will be by indirect methods is my 
conviction. It is not always so much what is said, as how and 
when it is said, that makes the lasting impression, and here the 
modern physical trainer can profit by noting some of the devices 
resorted to and the reasons assigned for doing things, by the 
best class of the old type athletic trainer. Most of these men have 
been close students of human nature, keen observers, quick to 
pick out the strong and weak points of youth. 

If the modern physical trainer and hygienist will add to his 
scientific knowledge the acumen and tact of his predecessor 
and competitor, his success in turning out "winners" will be 
quite as great, and render him a more potent factor in instilling 
hygienic truths and shaping the ideals and ambitions of our 
young men. Besides the inculcation of wholesome ways of living, 
the formation of correct habits and the avoidance of deleterious 



135 

things, he may be the means of developing good community 
or institutional feeling, a spirit that has high and sensible ideals 
relative to health matters. I believe it is within his power 
to create a veritable atmosphere of health that will far exceed 
in value the results of the ordinary direct method of learning 
mere facts. 

I recently had the opportunity of observing several such in- 
stances. I paid visits to a number of large boys' preparatory 
schools to study the methods in vogue in the physical depart- 
ments. Without exception the indirect method of teaching 
hygiene was most prominently and successfully employed. In 
two instances the head masters gave it as their unqualified opinion 
that the physical department did more to elevate the moral 
tone and physical condition of the student body than all the 
others combined. 

At one prominent boys' school in a New England state, having 
between three and four hundred students, a condition prevailed 
that was most ideal in these particulars. One man had the whole 
physical and athletic department under his control. No coaching 
or teaching was done by outsiders. All training, coaching 
and hygienic instruction was under the supervision of the physical 
director and student- assistant — one graduate assistant doing 
some work with the track and baseball men. Almost every 
student in the school was actively engaged in some form of ath- 
letics, and all took prescribed indoor work during the winter 
months when little outdoor work was possible. 

A stay of two days here revealed many facts relative to the 
efficient and ingenious methods of holding the boys up to high 
moral and physical standards; and most of these results were 
accomplished by indirect methods. 

The school spirit, interest in and loyalty to school affairs, 
and the intellectual, physical and moral standing of the students 
was as fine as I have ever seen. This was perhaps the more re- 
markable since many of these boys were from wealthy families 
and had not always been accustomed to strict, simple, systematic 
living and the more or less rigid school discipline. One matter 
in personal hygiene which greatly interested me was the instruc- 



136 

tion given for postural defects. All those who stood badly or 
had marked physical defects, that were likely to be remedied 
by physical effort and individual initiative, were put on what was 
known as the "stand-up squad" and compelled to take vigorous 
physical exercises designed to correct their defects. They were 
given instruction along this line in addition to the exercises 
and nothing exempted the fellows from these except marked 
improvement such as was clearly apparent to the director and 
other members of the teaching corps. Any who "graduated" 
from this squad and relapsed were again consigned to its ranks 
All spoke in the highest terms of the value of this method. 

The indirect hygienic instruction given to men on the football 
and baseball field, on the track and in the crew and at the training 
table constitute a body of useful information that may be drawn 
upon throughout life. And if designed with reference to the 
future as well as to immediate use, will inevitably result in great 
good. 

It has been well said that: "Sportsmanship is the application 
of the golden rule to athletics." Surely few educators would 
gainsay such a statement, and if this is the utterance of an im- 
portant truth, why should we hesitate to make concerted effort 
to exemplify it on the field and track, and who can better under- 
take this than those whose business it is to prepare for and oversee 
these activities. 

One of the great reasons why progress along these lines has 
not been more rapid is the tendency to subordinate the real 
physical needs and recreational activities of our youth to the 
competitive and spectacular end of sport. This undue prominence 
of what should be incidental, and the disposition to separate 
the physical department and the athletics, has retarded progress. 
They properly belong together and should be united and adminis- 
tered by one head. 

Dr. Hastings in discussing the qualifications and preparation 
of the physical director says: "I maintain that he should be 
called the director of hygiene and should have the training of 
the doctor of hygiene rather than that of the doctor of medicine, 
or simply the director of gymnastics The only reason 



137 

physical education has nominally absorbed all these functions 
is because school hygiene and the office of the director of school 
hygiene have not been created until recently and have, therefore, 
not asserted their legitimate place. Every physical director 
who is really up-to-date, is virtually a director of hygiene." 

Dr. Thomas A. Storey, of the College of City of New York, 
in discussing the departments of school hygiene and physical 
education, expresses the same thought in these words: "The 
fields of these two lines of work have broadened and overlapped 
until to-day they coincide; there can be no complete scheme of 
physical education without school hygiene." And it is worthy 
of note that Dr. Storey holds the position of "Professor and Di- 
rector of the Department of Instruction and Hygiene" in the 
institution named. If all the formal, direct lessons in hygiene 
could be further emphasized and reinforced indirectly through 
the medium of some selected physical activity without any sus- 
picion on the student's part that they were receiving instruction, 
how much more effective would be the results. 

It seems to be generally conceded that hygienic instruction 
has failed because it does not appeal to the interests of the student. 
This being the case all aids which make their appeal through 
avenues of recognized interest, with a minimum of emphasis 
upon the utilitarian aspects, deserve to be developed a ad en- 
couraged. It should be understood that this does not contem- 
plate the doing away with direct or formal methods. 

In conclusion, without attempting to further multiply examples 
in this or other fields, it may be said that indirect methods of 
teaching this branch have a distinct and important place in the 
educational curriculum, and should be used to supplement and 
apply the facts acquired through the ordinary methods; they 
meet a need which formal teaching fails to supply. 



XV. 

MEDICAL INSPECTION OF SCHOOLS FROM THE POINT 

OF VIEW OF THE HEALTH OFFICER. 1 

By J. F. Edwards, A.M., M.D., Superintendent, Bureau of Infectious Diseases, Dept. of 
Public Health, Pittsburgh, Pa. 

Conspicuous among present-day measures for the conservation 
of health are those directed toward infancy and childhood. 
Society is organizing to prevent waste at the threshold of life 
and its united effort has found expression in the American As- 
sociation for the Study and Prevention of Infant Mortality, 
whose initiation took place under the auspices of this body. 

Health boards recognize that the prevention of infant mor- 
tality is one of its most important fields of activity, and com- 
munities point with pride to their decreasing death-rate at this 
period of life. 

In medical inspection of schools and school children, the 
health officer recognizes the most favorable medium for con- 
tinuing the work of conservation through the most important 
years of growth and development. Indeed, he looks farther 
than this and sees in the schools his hopes of ultimate success 
in the control of preventable diseases and the establishing of 
right conditions of living. 

The health officer of to-day realizes that his work has a positive 
and constructive side as well as a negative or repressive one. 
The enforcement of quarantine laws, the abatement of nuisances 
and similar ex post facto activities, which not long ago were con- 
sidered the chief functions of the health officer, though necessary 
when occasion arises, represent work that can, at best, be only 
of temporary value. Even when his machinery for the control 
of transmissible diseases is working smoothly, when his measures 
for the correction of environmental conditions which exert an 
unfavorable influence upon the health of the community, are 
carried out, when food, water and milk are no longer a menace, 
when he has done what he can to save people in spite of them- 
selves, the health officer realizes that further progress and real 

1 Read at the Conference on Conservation of School Children, Lehigh University,. 
April 4, 1912. 



139 

success depend upon the knowledge and consequent coopera- 
tion of those whom he serves. He seeks to make his department 
an educational force in the community, but he finds that the edu- 
cation of the present adult generation in matters relating to health 
is difficult. The mass of the people have their ideas and preju- 
dices firmly fixed and half truths, built upon custom and tradition, 
are held tenaciously. It is for this reason that he turns to the 
school children of to-day, hoping that they, under the proper 
guidance and instruction, may acquire knowledge of health matters 
that will insure intelligent cooperation in public health measures 
and in habits of right living. This, however, involves the positive 
side of health education and health supervision, rather than 
the negative side of inspection alone. 

Medical inspection as practised in the majority of instances 
to-day must be looked upon as an expedient, made necessary, 
however, by conditions existing to-day in our schools and among 
our school population, but one that will be substituted by medical 
supervision, when the parents of tomorrow shall have been taught 
the principles of hygiene and right living as they should be taught 
in our schools and when schoolrooms, school curricula and 
the home itself no longer act as predisposing causes of disease 
and physical inefficiency. While working toward this ideal, 
however, we must do what we can for the present generation by 
medical inspection and supervision. This is necessary to-day 
and large expenditures of money by the state for this purpose 
are justified, because of the fact that a large proportion of school 
children suffer from preventable and remediable diseases or de- 
fects that have been unrecognized by their parents and for this 
reason have not received the necessary attention. 

Because of transmissible diseases, these children menace both 
the health and the school attendance of other children, and, be- 
cause of these and the non-communicable diseases or defects, 
their own physical development is retarded and they do not 
receive full value from their school course. Of no less importance 
is the medical inspection of the schoolrooms, the school en- 
vironment and school methods. Not only must the children 
be protected from infection and their physical defects be recognized 



140 

and corrected as far as possible, but the influence of the school 
itself must be such as will conserve and promote their health. 

It is apparent that many problems are involved and that upon 
their proper solution depends the health of the school child 
and the future physical vitality of the race. Both the health 
and the educational authorities are alike interested. They may 
look at the problem from different viewpoints, one emphasizing 
the improvement of health because this would lead to greater 
mental efficiency, the other emphasizing increased physical 
efficiency because of its bearing upon public health. The im- 
mediate object is the same — the health of the child. Whether 
the educational or the health authorities can best do the work has 
been the basis of much discussion. Hither one can do it when 
full cooperation exists, while, where this is absent, no system can 
meet with complete success. There can be no division of responsi- 
bility. It would be both unsatisfactory and expensive to have 
two sets of officials engaged in inspection work. One or the other 
must control and furnish the machinery. It matters not to the 
taxpayers who are the controlling authorities. They must, 
in either case, foot the bill. It is ultimately a question of efficiency. 
In the United States the question of school medical inspection 
has, in most instances, been one of expediency governed by local 
conditions, depending upon the readiness or equipment of one 
or the other authority to do the work. The practice is nearly 
equally divided with a probable tendency toward control by the 
school authorities themselves. It is not the purpose of the writer 
to produce arguments in favor of control by one or the other 
authorities. 

The health authorities in every community have well defined 
duties to perform, but to many questions relating to public health 
they have somewhat the same relation as the modern charity 
organization society has to the various philanthropies of the com- 
munity. They must see that health measures not necessary 
to be specifically under their control are organized properly 
and they must act as a clearing house of information and guidance, 
the object being to see that health work is being done efficiently, 
without duplication, and in correlation with its own direct ac- 



141 

tivities. In the majority of instances the initial activity of medical 
inspection has been directed toward the control of transmissible 
diseases. It has been frequently stated that the schools offer 
a favorable medium for the spread of infectious diseases, especially 
those commonly known as the contagious diseases of childhood. 
Some recent studies would seem to indicate that the importance 
of the school sessions as a causative factor in the prevalence of 
these diseases has been overestimated. Be this as it may, this 
negative phase is of much less importance than the fact that the 
schools offer a vantage ground for the control of such diseases. 
Not only are cases among the school children themselves ex- 
cluded, but other unreported cases in the family, or in families 
that have no school attendants, are detected and brought under 
supervision by the health authorities. 

Through the school attendants, combined with home visita- 
tion, and by a well organized intelligence service, practically 
the whole child population is brought under a surveillance such as 
could not be established except by school inspection. A number 
of such unreported cases, especially of measles and whooping- 
cough, occur, largely due to the fact that these diseases are not 
regarded as serious, especially among the poorer classes, and 
for this reason a physician is not consulted. The same is true 
of mild cases of diphtheria, which are thought to be cases of 
simple sore throat or tonsilitis. Where medical inspection ex- 
ists, the presence of an epidemic does not necessitate the closure 
of the schools. Diphtheria offers the best example of the possi- 
bility of efficient preventive measures. The taking of cultures 
will serve to eliminate danger from school attendance where 
this disease prevails. Medical inspection, by preventing infections, 
not only conserves the health of the school children and of the 
whole child population, but also serves to prevent loss in school 
attendance. While it may be assumed that this is the chief 
function of inspection by boards of health, and it is generally 
conceded that this work can best be done by these bodies, on 
account of the legal power over transmissible diseases expressly 
vested in them, this phase of inspection is of even less importance 
than that for the detection and correction of non-contagious 



142 

diseases and developmental defects, and of faulty school hy- 
giene. This, however, has not appealed as strongly to the general 
public as inspection for contagious diseases. This has been 
very generally recognized to be a necessary measure of community 
protection. In many localities, inspection for contagious diseases 
is the only form that has reached a considerable degree of com- 
pleteness and, in some instances, forms practically the only ac- 
tivity. As judged by available reports, this phase occupies 
about 75 per cent, of the time and energy spent in inspection. 
Such inspection, though valuable as far as it goes, does not have 
as far-reaching effects upon the health of the school children 
as the correction of defects and the placing of the child in the 
proper hygienic environment while at school, combined with the 
intelligent adjustment of the school studies to the capabilities 
of the child. 

While the statistics relating to contagious diseases may be 
regarded as definite and reliable, there is a lack of uniformity in 
statistics of other diseases and defects. 

With the progress in medical inspection that now obtains 
in the United States, there should be a greater uniformity. The 
time has come to have some standardization of scope and methods. 
There is a vast amount of literature on medical inspection, yet 
seldom are reports and statistics comparable. There is need for 
the correlation of statistics so that practical results that may 
serve as a basis for prevention and correction, may be deduced 
therefrom. It accomplishes but little good to pile up statistics 
unless these be combined in such a way as to throw light upon 
the causal conditions. If, for example, we have statistics of 
malnutrition we need to know what are its causes whether simply 
due to under-feeding, to home conditions or to bad teeth. Neither 
are there definite standards of sanitary requirements for school 
buildings. Opinions differ greatly as to what constitutes physical 
defects, concerning which action is to be taken. 

The greatest variations exist between the statistics of differ- 
ent localities. This variation is greater than could be accounted 
for by difference in physical development and is most probably 
due to difference in standards. While it is undoubtedly true 



H3 

that sufficient statistical data is available to emphasize the need 
of inspection, it would be difficult to form from them any satis- 
factory conclusion as to the physical condition of our child popu- 
lation as a whole. Hence, the keeping of records becomes a 
matter of the greatest importance. We are greatly in need of 
statistics wrjich bear upon the physical status of our whole popu- 
lation. No such data is available for the United States as exists 
in some European countries, where registration of vital statistics 
has been fairly complete for a long period of years, and where, 
also, compulsory military service affords an opportunity to collect 
data relating to the physical development of a large part of the 
population. In the United States medical inspection by statute 
can, at best, be a concern of states as the largest unit, but at 
present, medical inspection in any comprehensive way is enjoined 
by but few states. In the majority of instances it is a matter of 
smaller units, of cities and towns. There is no reason, however, 
why these should not employ methods found by practice to be 
the best. While adopting the standards already reached, every 
department of medical inspection should also be a bureau of 
investigation and research in problems of health and develop- 
ment in their relation to the science of pedagogics. 

The work of the trained physician, one who has become an 
expert in problems relating to the school child, is essential in 
our modern scheme of education. Something more adequate 
than ordinary routine inspection is necessary, however, in order 
to secure information upon which may be founded an effective 
system of education, which has for its basis the physical well- 
being of the child. It has been well said that "mental develop- 
ment without a true physical equivalent is unstable and un- 
desirable." The child whose brain is developed at the expense 
of his body is, from the point of view of society, an expensive 
luxury. 

Medical inspection is necessary in order that the teacher may 
be advised as to what should be the daily demands from each 
pupil and in order that his studies may not overtax his capacity ; 
and, on the other hand, that the idler may receive the necessary 
stimulus. 



144 

When children are excluded on account of transmissiole diseases, 
much stress is laid upon the necessity for continuing exclusion 
until the danger period for others has passed, but k is also the 
province of the inspector to consider the children themselves, 
whether they can resume their studies without injury to their 
own health. Many parents lose sight of this consideration 
and send their children back to school, where, in their attempt 
to make up for lost time, their health becomes permanently 
impaired. 

Scarcely secondary in importance to the medical inspection 
of school children themselves is that of the school environment. 
Much of the beneficial effect of inspection of the school children 
will have been lost if the sanitary and hygienic conditions in the 
schoolroom and on the school premises are such as will impair 
their health. There is no class of public buildings in which sani- 
tary requirements and hygienic fitness has been more disregarded 
than in some of our older school plants. The Committee on Med- 
ical Inspection of the American Medical Association quotes a 
writer as saying that the value of the public school buildings in 
America is $700,000,000 and states: "One-half of them are so 
abominable that they should be torn down forthwith and a quarter 
more of them should be reconstructed." 

The committee makes the following recommendations : 

1. The endorsement of certain standards and requirements in the planning 
and maintenance of school buildings and grounds by state and national 
educational and medical organizations. 

2 The enactment of legislation which will define these standards and 
insure the erection and maintenance of school buildings in accordance there- 
with. 

The most common hygienic defects found in the school build- 
ings themselves are inadequate ventilation, improper lighting 
and faulty location and equipment of toilet conveniences. School- 
rooms are often overcrowded and when this is combined with 
insufficient provision for change of air, the result is disastrous 
to the health of the child and forms the chief cause of morbidity 
among our school population. The problem of ventilation of 
schoolrooms is extremely difficult and in its solution the edu- 
cational authorities need the advice of the physician or the sani- 



145 

tary engineer. In warm weather the problem is simple, needing 
only the opened windows, but in cold weather it is more complex, 
the difficulty being largely a question of heating and humidity. 
To approach the proper standard, each child should have at least 
20 square feet of floor space, 300 cubic feet of air space, with 
a change of air every eight minutes. During recess periods the 
windows should be opened, so that there may be a complete 
change of air. Dust should be eliminated as far as possible by 
proper cleaning methods, both of blackboard and floors. 

The necessity for open air schools for certain classes of children 
is recognized to-day and has become a matter for the attention 
of educational and health authorities. Midway between these 
and the ordinary schools are what may be termed cold room schools 
where windows are kept widely open in all seasons. These 
are much less expensive to maintain and are available for every 
community. The supervision of school appliances is a necessary 
part of inspection. The desk should be suited to the child. 
Many instances of faulty development may be traced to improper 
positions assumed during school hours. 

The physical characteristics of text-books is a question of 
importance as affecting the vision of school children. The kind 
of type, the width of line and margins and the finish of the paper 
are all questions that need the careful consideration of the student 
of school hygiene. 

The common drinking-cup is a prolific source of infection and 
must give away to bubbling fountains or the individual paper 
cup. Schoolbooks and pencils may be a source of infection; 
the latter at least should not be used interchangeably, and books 
used by a pupil excluded on account of one of the contagious 
diseases should be destroyed, for we yet lack a satisfactory 
method of disinfecting books. 

The hygiene of the schoolroom needs constant supervision, 
for the children are compelled by the state to attend school 
and, therefore, it should provide them with the most approved 
hygienic environment. 

One of the most important phases of medical inspection and 
supervision of schools and school children is that which links 



146 

it to the home itself. Medical inspection loses much of its effi- 
ciency unless its machinery be extended to securing the coopera- 
tion of the parents in giving the children the necessary attention 
for the diseases and defects found by inspection. The influence 
of the school should go further than this and be exerted toward 
the correction of living conditions that affect the children in- 
juriously. For this work the school nurse is essential, and in 
every complete system of inspection, a force of nurses, trained 
as social workers, is necessary to carry out the work to ultimate 
completion. They, better than the educator or even the physician 
himself, can succeed in bringing home the responsibility to the 
parents. 

Much of the objection to medical inspection has arisen because 
of the belief that it is too paternal in its scope, that it takes away 
the responsibility from the parents. In practice, however, the 
reverse is true. Instead of taking away parental responsibility, 
it develops it because it increases their knowledge of their chil- 
dren's needs. In many homes the mere taking home of a slip, 
informing the parents to take the child to their family physician, 
is not enough. They do not see the necessity for such a pro- 
cedure. Their child is able to be up and about, and they cannot 
see any need for taking it to a doctor and incurring extra expense. 
It is in such cases that the nurse can give the necessary explana- 
tion and if, in addition, the family is unable to pay for treatment, 
can make arrangement for it at some hospital, or out-patient 
clinic. This form of follow-up treatment is most important. 
Without it the percentage of corrections is small. 

In the securing of corrections, the cooperation of the physicians, 
the dispensaries and hospitals is necessary and here lies a most 
difficult problem. It is necessary to avoid increasing dependency 
and, therefore, medical service should not be placed on a purely 
charitable basis, except when this, after careful investigation, is 
found to be necessary. In addition to the work of the nurse in 
the home, the school has a most important function as a center 
of social work in the community. Much can be accomplished by 
small groups in mothers' classes and by lectures to the parents 



147 

that will bring them into closer association with the work of the 
schools. 

The chief need for health work in connection with the schools 
to-day is for central supervision of all work relating to the health 
of the school child. In each large city, there should be a depart- 
ment of school hygiene under the supervision of a trained physi- 
cian, who can give his time to the work, acting as adviser to the 
school authorities and as an executive in carrying out the different 
lines of work. Among other activities in addition to supervision 
of medical inspection and supervision of the hygiene of the school- 
room would be the physical examination of teachers and their 
instruction in practical hygiene; the outlining of a course of 
instruction in hygiene for the pupils themselves; the directing 
of work in psycho-clinical problems relating to the child, includ- 
ing subnormal and supernormal children; supervision of play- 
grounds and playground schools; supervision of physical training 
and athletics; and, finally this department should make use of 
all information gained in school for the improvement of community 
health. In rural districts this work could well be done by a med- 
ical officer, acting through the office of the county superintendent. 

In any system the closest cooperation between the health 
and educational authorities is essential. 



XVI. 

MEDICAL INSPECTION IN SCHOOLS FROM THE STAND- 
POINT OF THE EDUCATOR. 1 

By Thomas A. Storey, M.D., Ph.D., Professor of Hygiene, College of the City of New York. 

There are four great reasons why every school should organize 
and perpetuate an effective system of medical inspection. Each 
one of these reasons alone offers enough serious argument to secure 
the establishment of medical inspection in all schools. Taken 
altogether they present a case that ought to convince any intelli- 
gent community. 

The first reason for medical inspection in schools is concerned 
with communicable disease. The report of the medical officer 
of the London County Council for the year ending December 
31st, 1909, indicates that scarlet fever alone affected 10 per cent, 
of the children enrolled under the educational authority of 
London. Any plan of medical supervision which will reduce 
or eliminate the spread of communicable disease among school 
children will enormously increase the educational efficiency of 
the school system. With an effective system of medical in- 
spection in general operation, there would be a consequent 
reduction in child mortality; a consequent reduction in the 
occurrence of incapacitating physical defects the sequelae of 
communicable disease; and a consequent reduction in pupil 
absences from school on account of such illness, convalescence 
and organic weakness. School men are united in the con- 
clusion that absence is one of the most important of the dis- 
turbing factors that interfere with the efficiency of the school 
curriculum. This is true not only because of the effect of 
the absence upon the work of the individual that has been ab- 
sent, but also because of its effect upon the classmates whose 
recitations have been disturbed in content and routine. In 
this way, through its influence on school absences alone, the im- 
mediate results and the after-results of disease have a vital effect 
upon the quality and quantity of educational work which can 

1 Read at the Conference on Conservation of School Children, Lehigh University, 
April 4, 1912. 



149 

be accomplished in any given school. We must leave out of 
consideration here our common interest in saving human life 
and reducing human suffering. No individual or group of in- 
dividuals can claim priority in such interest. That interest alone 
is sufficient argument for having general medical inspection 
everywhere, and cannot be regarded as an argument against 
placing that inspection in the school. From the facts that I have 
given above it must be evident that no public servant has more 
right or reason to advocate an efficient medical inspection of 
school children than has the school man. He has not only the 
interest that is common to all humanity. He has an additional 
interest because of the intimate relationship of medical inspec- 
tion to the success of his life work. 

The second reason for medical inspection in schools is con- 
cerned with remediable incapacitating physical defects. 

It was reported in 1906 that over 20 per cent, of the children 
in the schools of New York City had defective vision, and over 
50 per cent, had defective teeth. 

Statistical inspections of school children made all over the world 
indicate the common presence of a variety of physical defects. 
We find defective vision, decayed teeth, diseased gums, obstructed 
breathing and middle ear troubles everywhere. I might add 
to the list. These defective conditions are known to have a more 
or less detrimental influence upon the quality and quantity of 
school work the child can do. They also have an influence upon 
the resistance of the child to acute disease, thus decreasing his 
health resource and making him liable to increasing inefficiency 
in his school work. 

These conditions are amenable to treatment. After success- 
ful treatment the child enters into better general health. His 
functional efficiency is improved. He is better able to accomplish 
good work in school. His mental efficiency increases with his 
health efficiency, and his educational possibilities are enlarged 
with the disappearance of restrictive, incapacitating physical 
defects. He is likely to be no longer a drag on his class, unable 
to do good work himself and interfering with the progress of his 
classmates. 



150 

Here again the school man finds results from medical inspec- 
tion that are in direct relationship with his work and his interests. 
We are all concerned with increasing the health possibilities 
of all humanity, and the school man is as much interested as any 
one else. But in addition he is more vitally concerned than is 
any other public servant in the correction of incapacitating 
health-destroying physical defects which limit the power of the 
school child to study and to learn. The best success of his efforts 
depends upon the proper treatment of children whose work is 
retarded by such physical defects, not only because this treat- 
ment may enable the child to do better work, but also because 
the child minus his defects is no longer an obstacle to the academic 
advance of his classmates. 

The third great reason for medical inspection in schools is 
concerned with irremediable physical defects. 

The crippled, the deformed and the delinquent whose incapaci- 
tating defects are permanent should be found and classified. 
The detection of such children and their subsequent classification 
and their final special instruction opens educational possibilities 
for those irremediable defectives that are unknown and un- 
attainable without a system of medical inspection. They, 
more than the remediable defectives, are retarding factors in 
the school progress of normal children. Their separation and 
independent instruction, like the treatment of children with 
remediable defects, works to the distinct advantage not only 
of the individual concerned, but also to the general class of normal 
children with whose progress they would otherwise interfere. 

From the point of view of the educator, the cripple, the deviate 
and the delinquent deserve serious consideration. No other 
member of the community save the child and its parents can have 
even nearly the legitimate and real interest in these cases that 
he has. 

The fourth reason for medical inspection in schools is concerned 
with the development of hygienic habits in school children. 

With an effective system of medical inspection, the pupils 
and their parents get into the habit of looking after those influences 
that affect personal health. The medical inspector that dis- 



i5i 

covers dirty teeth and requires the child to report later with 
clean teeth is securing an influence on that child's habits which 
may extend to include that child's children. The public schools 
of every large city in the world are infested with head lice. After 
the medical inspector shall have required a few generations of 
children to be cleaned up, there will be a generally educated 
public, and more and more children will arrive in school with 
habits of cleanliness that will not permit them to have pediculosis. 
Statements of this sort may be legitimately applied to all pro- 
cedures in medical inspection which result in the removal or 
correction of defects in health and hygiene. 

In addition, medical inspection offers the most direct and 
effective method of getting acquainted with the hygienic habits 
of the individual. The examiner may learn seriously important 
facts concerning the child's habits of eating, sleeping, excretion 
and bathing, and about his care of the eyes, teeth, skin and all 
the other various and important hygienic habits which form a 
basis for human health and efficiency. 

Looked at from the view-point of society in general, medical 
inspection which influences the health habits of the masses 
is a matter of supreme importance. The school man feels this 
as keenly as any other member of society, but in addition he 
realizes that a successful educational influence of this sort means 
that he will have children of cleaner habits to teach in his classes ; 
that he will have healthier children to instruct; and that his 
general educational plans will have fewer interruptions and 
disturbances from absence, abnormality, and physical defect. 

I have stated four very important reasons for medical inspec- 
tion in schools. They are reasons that appeal to society in general. 
They are reasons that appeal particularly to the taxpayer and 
lead him to back up medical inspection because it inevitably 
makes his investment of taxes more remunerative. He has 
a right to demand that the children on whom the community 
is spending his money shall be given every opportunity to take 
a fair average advantage of that expenditure. He ought to rise 
in his wrath over the inconsistency of allowing a remediable, 
incapacitating physical defect to remain uncorrected in a school 



152 

child. A child with defective vision which is not given glasses 
— granted that glasses would correct the defect — is wasting public 
money. 

The educator views medical inspection in schools from the 
point of view of general society, and feels about it as any sane 
human being would feel. He views medical inspection from the 
view-point of the taxpayer and feels like a taxpayer. But, 
finally, he views medical inspection from his own point of view 
and finds that he, of all members of society; that he, of all public 
servants, is most affected by the results of a successful plan of 
medical inspection. 

These four reasons justify the educator in advocating the 
establishment of medical inspection in schools. But it is one 
thing to establish a system of medical inspection and quite 
another thing to make that system succeed. In my experience 
I have learned that there are three requisites to the success 
of any system of medical inspection. I will not discuss certain 
other requisites that are essential to the success of any human 
enterprise. The ultimate value of any system for any purpose 
depends largely upon the character and the equipment of the 
men that attempt to apply the system. In this connection 
I would like to call your attention to a statement made by Pro- 
fessor Hill, of Tulane University, at a meeting of the American 
School Hygiene Association, last week. Professor Hill stated 
that only 9 per cent, of the medical profession has gone farther 
than the high school in their academic education. The impor- 
tance of this fact in its relation to the success of a system of medical 
inspection in any given school cannot be overlooked. Good 
men and capable men and tactful men and men educated for 
the job whatever the job may be are essential. These things 
and all that they imply are just as necessary to the success of 
a system of medical inspection as they are to the success of any 
other system. I will refer only to such essentials in passing be- 
cause their relationship is obvious. There are, however, three 
other requisites which are peculiar in their relationship to medical 
inspection. 

In the first place, it is absolutely essential that a system of 



153 

medical inspection should provide physical examinations which 
will uncover the anatomic, physiologic and hygienic conditions 
that affect the health of school children. An examination that 
is anthropologic rather than medical will fail so far as medical 
inspection is concerned. An examination that is statistical 
rather than advisory is of little use to the child or the school. 
The details of any local plan of examination should fit local 
conditions. And whatever the system of examinations may 
be, it must be a real system and it must be a practical system. 
A system that exists only on paper is worthless. A system that 
does not look for common diseases, common abnormalities and 
common faults in hygiene cannot be a satisfactory system. 

Second, it is absolutely essential to the success of a system 
of medical inspection that every piece of advice given a child 
should be followed up if it is the sort of advice that can be followed 
up. It and its ultimate fate should be recorded with the record 
of the original examination. For instance, it is a waste of time 
to record the presence of decayed teeth and advise their treat- 
ment if nothing is done to stimulate the child's parent or guardian 
to secure treatment. It is not worth while to tell a child he has 
poor vision unless you require the child to bring you a note stat- 
ing that the fact has been brought to the attention of the parent, 
and stating that he will or will not have the defect corrected. 
Every promise of that sort should be followed up. It is irritating 
to the family, the family physician, and to the clinic to receive 
a child term after term with the same note from the school doctor 
concerning a defect of the nose or of the eye or something else 
which previous treatment has failed to correct, and for which 
further treatment is not considered advisable or concerning 
which there is a legitimate difference of medical opinion. If 
the medical inspector follows up each case he will in his natural 
routine find out if paternal promises have been made good. 
If not, he may send a second note to the father or even a third 
one. If, on the other hand, he has a case in which a special 
reason has been found for not administering further treatment, 
he will not irritate the father and the family advisers by repeated 
notes with reference to the need(?) for treatment. 



154 

An effective "follow up" system will enable the medical inspector 
to enforce the sections of the Sanitary Code as they apply to 
contagious and communicable diseases. It is a waste of time for 
the Board of Health to send to the schools printed lists containing 
the names and addresses of families in which such diseases have 
appeared on the preceding day unless the school is able to check 
up the list, identify children who have been exposed, and exclude 
them from attendance until the Board of Health issues its certifi- 
cate of re-admission. 

A "follow up" system is as essential to the success of medical 
inspection as its system of medical examinations are. In fact, 
after medical inspection has accumulated a certain amount 
of statistical material it is of no further use unless it is backed 
up by an effective "follow up" system. 

Third, no system of medical inspection in schools can be com- 
plete and permanently successful which does not eventually edu- 
cate the parent or the child to a sympathetic and cooperative 
relationship with the system. If the majority of people in a given 
community are not in intelligent sympathy with medical inspec- 
tion in schools, the system cannot last. On the other hand, 
if the practical health reasons are given for the advice carried 
home by the child, the parent will see their value and he will 
be ready to cooperate. There is no difficulty in securing the co- 
operation of the average parent when dental service is needed, 
provided the parent realizes the importance of such service. 
This is true of the whole scope of medical inspection. The child 
and the parent must be given an intelligent knowledge of the 
relation between medical inspection, hygienic habits and health. 

Medical inspection is, after all, a force working for a better 
general education in personal hygiene. It is a mistake to teach 
hygiene in a recitation room and make medical inspections in 
the examining room without ever pointing out the relationship 
between the two. In one situation the teacher presents, for in- 
stance, the facts regarding the importance of clean teeth. In 
the other the school doctor finds dirty teeth. In the one place, 
the child learns what will happen if his teeth are chronically 
dirty. In the other place, he is advised to clean his teeth, and 



155 

asked to report later to show what he has accomplished. Surely 
these situations are part of the same problem in education. 
It is certainly a mistake not to bring them together and secure 
an impressive educational influence upon the children concerned. 

From the point of view of the educator, the four great reasons 
for establishing medical inspection in schools and the three 
essentials to the success of such a system are all serious reasons 
why medical inspection should be intimately related to the 
whole educational system in any given school. 

If a system of medical inspection must be a practical system, 
a system that will work, then it must be a system in sympathetic 
relationship with the general management of the school. If 
it is to take a place in the school curriculum it should be under 
the same responsible control that covers the other members of 
that curriculum. If it is related to absences — and it must be 
so related — the relationship should be one of academic sympathy 
and a part of the school system itself. If medical inspection 
must follow up cases in order that its work may be effective, 
the "follow up" must be made through the regular school channels 
and in the regular way. If medical inspection must have an edu- 
cational influence upon the hygienic habits of the school child, 
then its plan of instruction should be pedagogic and under the 
supervision of the school authorities. If the results of medical 
inspection are so directly related to the success of the child 
in his school work and so to the success of the whole work of the 
school, then surely medical inspection should be a part of the 
very organization of the school itself. 

From the point of view of the educator, medical inspection 
carried out in school by a department of the school has a far 
greater probability of success and efficiency than a system ap- 
plied in the schools by a department outside the school and with- 
out responsibility to, or control from, the school. 

I have been for six years in charge of a department which has 
had medical inspection for a part of its work. This system 
of inspection has been developed by the school authorities, and 
has reached a high degree of efficiency. Medical inspection, 
like every other phase of my work, is under control of the school 



156 

authorities just as all other departments in this institution are 
under such control. I could not ask for a more satisfactory 
relationship. 

During the year ending June i, 191 1, these medical inspections 
brought us into relationship with 3,500 boys. We came in con- 
tact with these boys on this basis over 15,000 times. These 
"contacts" were made up of regular medical examinations 
consultations and "follow up" conferences. Every case of 
communicable or infectious disease, every case of physical defect, 
and every case of obvious faulty health habit was given advice. 
Every variety of advice that admits of being followed up was 
followed up. 

Our results as shown by our "follow up" system indicate that 
for the year ending June 1, 191 1, the parents of 980 of our boys 
followed our advice and consulted with 580 physicians; the parents 
of 1,150 of our boys followed our advice and consulted with 536 
dentists; the parents of 83 boys secured the service of 41 opticians; 
the parents of 108 boys sent their sons to 37 free clinics; and the 
parents of 78 boys sent their sons to free dental clinics. 

We find here a basis for great satisfaction, when we realize 
that these figures mean that during that year the parents of 
over two thousand boys were sufficiently interested in the im- 
provement of the health of their sons as to pay for the legitimate 
services of over 1,100 expert advisers; and that for those services 
these parents paid on a conservative estimate over $12,000. 
We know that in a later period, in three months, the parents of 
five hundred boys spent over $3,500, upon such service. 

Statistics for a term of four months ending February 1, 191 2, 
indicate that advice was given to about one thousand boys 
during that term. Half this number received advice concerning 
health habits which advice they could utilize without consulting 
a regular family adviser. The other half were advised concerning 
physical conditions that needed expert treatment. We find 
that 94 per cent, of those boys were sent by their parents to their 
private advisers, and that only 6 per cent, went to free clinics. 

During the last five years this department has had recorded 
this relationship with about seven thousand boys, most of whom 



157 

on the first examination were members of our preparatory de- 
partment and of the high school age. By the end of this year 
we will have come into contact with these boys, while they have 
been in regular attendance, over 50,000 times. I have no figures 
covering this whole period, but if the results uncovered by our 
"follow up" system for the last year and a half are comparable, 
I judge that the medical inspection as carried out in this school 
has affected five or six thousand boys and through them has had 
an influence upon the health habits of five or six thousand families. 
I take it this influence is real because we definitely plan to instruct 
each boy concerning the reasons for the procedures which we fol- 
low and to which he must submit. We certainly secure the co- 
operation of most of our boys, and the expenditures made by 
parents as reported by their sons would indicate that those 
parents were in sympathy with our plan of instruction. Only 
2 / 3 of one per cent, of our boys are dismissed from school for 
failure to report in the "follow up" conference and only 7 / 10 of one 
per cent, of the parents of these boys refuse to seek expert advice 
after we have recommended that they do so. 

In conclusion, I must say that the four great reasons which 
I have maintained justify medical inspection in schools are the 
reasons which have led an educational institution, the College 
of the City of New York, to make medical inspection a part of 
its plan for the individual instruction of its preparatory and 
collegiate students in matters of personal hygiene; and that the 
three essentials which I have claimed are requisite for the success 
of a system of medical inspection are essentials which have been 
incorporated in the system organized by this institution; and, 
finally, that the net results of this system of medical inspection 
which has been organized, administered, and supported by this 
educational institution amply justify its plan of organization, 
its operation and the nature of its control. 



XVII. 

"THE PREVENTION OF INFECTION OF THE RESPIR- 
ATORY TRACT IN THE SCHOOLS." 1 

By William Charles White, M.D., Prof, of Medicine, University of Pittsburgh, Medical 
Director, Tuberculosis League, Pittsburgh. 

The time has come when to many there appears the necessity 
for determining how long the earth's inhabitants, at their present 
rate of increase, can subsist on the visible supply of the necessities 
for maintenance. The visible supply of necessities refers mainly 
to: 

First, those materials which provide warmth for the dwellings, 
such as coal, wood, and water power, etc. 

Second, those materials which provide the means of manufac- 
ture of necessities and transportation, such as coal and iron. 

To some, it appears that the application of the Malthusian 
principle of population is imminent. In other words, that the 
population is increasing so rapidly in proportion to the increase 
of food supply that there is grave danger ahead of us. 

That the importance of these issues are apparent to various 
governments is evident in their plans and commissions for con- 
servation. Studies of the high cost of living have induced the 
President, through his consular agencies, to urge an international 
inquiry because he finds that the increase in the cost of living is 
universal and there are multiplied evidences of the universal 
restlessness under these conditions. As a matter of fact, Malthus 
predicted what has come so near us and the high cost of living 
is really too many people to feed with the available food and we 
have no one on earth to perform the miracle of the loaves and 
fishes. 

I do not wish to be misunderstood. There are vast territories 
yet to be peopled such as Canada, Africa, New Zealand, and 
South America and the possibilities of food from land and sea 
are far greater than many times the requirement for the present 

1 Read at the Conference on the Conservation of School Children, Lehigh University, 
April 4, 1912. 



159 

earth's population, but to-day the available food is less than the 
necessities for the population. 

That the inhabitants of many countries, consciously or un- 
consciously, realize this and individually attempt to avoid the 
demand of support which progeny enforces on them, is evidenced 
by the falling birth-rate of the most civilized parts of the universe. 
The sexes still marry but they stop producing as many children. 
France has for years been disturbed by its falling birth-rate. 
In Prussia and Germany, the constant decrease in the birth-rate 
has called for strenuous measures. A commission in these 
countries to study the problem found that the decrease affects 
the legitimate fertility. The number of marriages has remained 
the same. There is no diminution in the reproductive capacity 
of either sex. The conclusions are, I am sure, applicable to all 
countries. Let your minds dwell on the small families of your 
married friends and the answer is plain. 

England faces it, and Bernard Shaw places the blame on the 
500,000 spinsters, but the German commission is nearer the truth. 
United States, to its shame, has no record of its birth-rate as a 
whole, and only for the past few years for any part of it, but if a 
study be made of the tables on p. 18, Bulletin 109, U. S. Depart- 
ment of Commerce and Labor, the striking reduction of the birth- 
rate in some of the eastern towns and states is appalling. Rhode 
Island had in 19 10 less than one-half the births of 1908. 

Opposed in a measure to the great army of child producers 
who are, in one way or another, curtailing the supply, is a growing 
army of conservationists to which we belong. The great aim 
of this group of workers is to conserve and retain for future 
usefulness those children who escape the vigilance of their fore- 
bears and get born. To us every child is a treasure of growing 
value the more we spend upon it in feeding and educating it. 

The large majority of children are anticipated with a supply 
of clothing and utensils and from the day of birth are an increas- 
ing expense. This outlay of money and time in raising children is 
much increased during sickness and totally lost by the death of 
the child. 

That the group of conservationists, to which belong physicians 



i6o 

and charities as well as health organizations of public and private 
character, has had a tremendous influence is evidenced by the 
falling death-rate which for the cities of the world varies from 
17 per cent, to 49.5 per cent, decrease for every 1000 persons 
living, and this has taken place in spite of an increased death- 
rate over 40 years of age. The vast saving has come in the earlier 
years of life. 

While a great loss undoubtedly results from death and we are 
likely to be led astray by the figures relating to death, it is only 
because figures relating to loss through sickness are not yet avail- 
able that we have neglected this side of the question. Many of 
those whom we have spent money on, die. This number, however, 
as pointed out, is being satisfactorily reduced. A far more serious 
loss and expense is due to avoidable illness. 

Among the causes of sickness which produce a very heavy 
annual expenditure of a more or less unnecessary nature is the 
great group of respiratory tract infections — enlarged tonsils, 
adenoids, coughs and colds, bronchitis, tracheitis, etc., with their 
complications. These infections are due largely to the coccus 
group of organisms with liberal assistance from the diphtheria 
bacillus, the tubercle bacillus, and the influenza bacillus. It 
is impossible to compute the annual loss and suffering from this 
group of diseases or to even prospect upon the foundation laid 
by them for future more serious maladies. We cannot so much 
as state with positiveness that the constant tampering with the 
immunity of different ages which such infections seem to inflict 
on the general resistance is a fact and yet we cannot watch the 
gradual invasion of infective rheumatism, infective cardiac lesions 
and St. Vitus Dance in the subjects of frequent tonsillar and ade- 
noid infections without the suspicion of some close relation be- 
tween the respiratory tract invasions and future fatal infections. 
Be this as it may, the common colds, coughs, enlarged tonsils, 
adenoids, pneumonias, etc., cause more sickness than any other 
one thing or group of things, and are consequently the source 
of greatest waste. After watching a large number of poor chil- 
dren in the dispensary and over 500 orphans in the Presbyterian 
Orphanage for some years, in and out of homes, in and out of 



i6i 

schools closed and open, I am convinced that the three funda- 
mental causes in producing sickness from these infections in 
children, in addition to the specific infective agents spread by 
coughing, sneezing, and spitting, are poor food, poor air, and 
too little rest, which materially lower the resistance. 

The infecting agents will be for a long time constantly present, 
but in spite of their presence, if the immunity be raised by in- 
creased food, better air and more rest the infection will soon dis- 
appear or not occur in spite of the presence of the infecting agent. 
This has been proven so often that there can be no argument on 
the other side save that offered by isolated cases. No one who 
has watched the development of open air schools and their re- 
sults can for a moment question the value of more food, fresh 
air and more rest. I have now two such schools under my care — 
one, the second in the United States for open-air treatment of 
tuberculous children, and one, the first of its kind for children 
culled from the inmates of a large orphanage — the most progressive 
of its kind. And it is miraculous how quickly the almost universal > 
coughs, running noses, and sputum of the children clear up with 
more food, fresh air and rest, how rapidly the tonsils reduce 
in size and how free they remain from future infections until 
they again return to former conditions. 

That we have so long as a nation failed to see the teaching 
of these facts is the more curious since the children are absolutely 
under the control of the state from 9 a.m. to 4 p.m. with a short 
mid-day intermission. When the possibilities of a better condi- 
tion of affairs is apparently in the hands of authority, it behooves 
us to ask why the changes have not come more rapidly. In 
the first place, we must remember that most of the improve- 
ments in health work are tried out on a small scale by the voluntary 
organizations. If these experiments are successful, the popular 
demand becomes so strong that authority begins to enforce the 
law. One able political leader expressed to me in conversation 
that he was unable to give the public more than the public would 
take. This is the general political view. We have had evidence 
in this state but more especially in certain of the larger munici- 
palities that this is not so. 



l62 

In general, I think much of the trouble comes from the lack 
of sympathy between the official health administration, and 
voluntary health work, and to a lack of the spirit which desires 
only the highest achievement of public good which can alone 
come from a proper correlation of all working factors and a dis- 
tribution of labor among these from some legally constituted 
head. 

Among the reasons for our slow progress in securing desired 
results in this field, I would place: 

ist. Our political appointed, generally inefficient health officers. 

2nd. The political status of our school boards. 

3rd. The lack of cooperation in efforts by administrators of 
health laws, physicians, and educators. 

I have long dreamed of the day when health officers would 
appear in the land of a broad enough type to initiate a correla- 
tion of all agencies in any municipality. The routine of the health 
office runs in such a way as to allow the head time for construc- 
tive work His voice before boards of education, charities, hos- 
pitals, etc., pointing the way for cooperation, leading the dissoci- 
ated groups to a common purpose, demanding uniformity on 
all operations touching public health questions which are clearly 
defined by law, would meet with immediate response. If volun- 
tary agencies can do it, how vastly more could be done by an 
agent backed by law. 

Some day such men will appear, then we will have reached 
that point in conservation which we desire and in municipal 
autonomy of local agencies centralized in a legal chief, with a 
proper correlation of the work of the different factors, public 
and voluntary, we will attain the highest point of efficiency in 
the struggle for a healthy race. 

Bedford and Wandless Sts., 
Pittsburgh, Pa. 

DISCUSSION. 

Dr. Watson L. Savage, Pittsburgh: 

It hardly seems that I would have much to add, or that I could add to what 
has been said, but I have brought here to-day a concrete example of what is 
possible under different environment, and what I say, I trust you will take, 
not to mean a criticism on the efforts that have been made in Pittsburgh, 



1 63 

where you may know one of the greatest works has been done in health and 
where they reduced the problem from one of the worst living places in the 
world to the third city in the country in low-death rate. 

I have listened with great interest to the papers of the previous speakers 
upon the question of school medical inspection, and feel that the subject is 
presented here to-day at a most opportune time. 

We in Pennsylvania are just reorganizing our schools under what is known 
as the New Code, which will afford, we hope, many opportunities for in- 
stituting new and important features in the school problem. It was with 
this fact in view that I believe the committee arranged for this program, 
and I hope what we have heard to-day from those who have had large and wide 
experience in this problem will not only be taken seriously by our educators, 
but that definite and positive action will be taken to bring about a very much 
improved condition of child health in the State of Pennsylvania. 

Statistics tell us that more than one-half of all sickness is due to ignorance, 
and therefore it would seem the greatest progress to be made in this campaign 
against disease must be done through education, and the movements which 
will make for safer and more healthful conditions in our schools must come 
through the education of the masses. It is not only necessary to educate 
our children, but also the parents of the children must be brought to realize 
the importance of those things which will prevent disease. 

It has long been my belief and practice that the medical inspection and 
examination of the pupil is far more valuable than the statistical or anthropo- 
metrical, but it has also been a known fact that the medical examination 
oftentimes can only be obtained through the statistical, as many parents 
might object to a medical examination where few would object to a child 
having his measurements taken. Therefore, the taking of measurements 
has been a means to an end, and that end is the making of proper observa- 
tions and examinations of the individual students. When these observa- 
tions have been made, it is of special importance that the pupil and also the 
parents be made aware of the condition, and proper steps be taken to correct 
it, in other words, by the "follow-up" system the processes of education are 
driven home. It is not enough that we note defects but it should be possible 
to enforce correction and if need be make laws to this end. 

In connection with these observations, it is interesting to note the work 
that is being done at the Carnegie Technical Schools. Two years ago there 
was begun in these schools a series of studies and observations upon the enter- 
ing students, all of whom were carefully examined by the physician in at- 
tendance, as to their physical well-being, strength and efficiency, the object 
being to detect all the physical defects and single out all students who seemed 
to be very slow in physical efficiency, requiring them to have corrected any 
physical defect which would seem to the examiners to prevent their main- 
taining the best physical power. 

After getting together the first series of tests and examinations, it was 



• 



164 

found that such a large percentage of the men fell below what was estimated 
to be a very low passing standard, that on making my report to the director 
I advised him not to make public the findings, as they seemed so poor that 
I could scarcely believe the results and there might be some errors in the 
observations, or the methods ixsed in determining the values. A second series 
of examinations have just been completed of the entering men, and although 
we have carefully checked up all our instruments and gone over the previous 
work, we find that this series of examinations bear out those of last year, 
and I therefore feel safe in making my report to the director of the result 
of the examinations of students in the Carnegie day courses. 

In the first place, as last year, the physical index and vital index of our 
entering students is exceedingly low, and the health index likewise. Is this 
due to climate, housing, nutrition or what? I cannot fail to attribute this 
condition in a large measure to the inefficient methods of student inspection 
and physical training in the Pittsburgh district, as our students are largely 
drawn from this district. This means a lack of systematic examinations 
or "follow up" and thorough physical training in all our preparatory schools, 
beginning with the grammar schools and continuing throughout the high 
school courses. 

I have never seen so low a physical condition in any body of students as we 
have at the present time in the technical schools, and the examination of the 
second series of men coincides very closely with the series of last year, 
so that the condition of the entering men this year seems to be practically 
the same as last, but other factors are apparent, upon second examination 
of last year's students, the most striking of which is that of the men who were 
conditioned in the department of student health because of failure to main- 
tain their health indices, and correct errors pointed out, 83 per cent, of the 
science men have fallen out of college, 85 per cent, of the design men have 
likewise failed to continue in school, and 70 per cent, of the school of applied 
industries. This fact brings strongly before our minds the close relation 
between physical efficiency and success. 

In the light of these observations I believe that we have conclusively proven 
that the physical condition of our men in this district is not ready for an 
optional course in student health, and I believe that we are compelled to make 
provision, at least in the plebe year, for a prescribed course in physical train- 
ing to the whole student body, with power to enforce in the hope that we may, 
by so doing, considerably lessen the large percentage of failures as shown by 
this report, and by other reports that have been the source of considerable 
anxiety in our schools, i. e., the great number of men failing to complete 
their courses. It would seem that the health is a larger factor than had been 
charged to this account. 

This report indicates also that medical inspection of school children under 
the board of health is not performing its full duty, and it is my belief that that 
can be done only by the education of the pupil, the education of the parents, 



i65 

and the education of the public, and the proper department for this work 
to be carried on under is the physical training where the teacher gives the 
whole time to the work. Men and women in this department must be trained 
not only in gymnastics, but also and more important in hygiene, diagnosis, 
student and school inspection, sanitation, and preventive medicine. This 
department meets all the students in every grade and gets closer to the 
individual than any other, following them from year to year in their working 
as well as play hours, hence it is able to exert the greatest influence and is the 
logical and economical place to prevent disease, educate the pupil to protect 
the family and child of the future. The department however must be headed 
by a physician of highest standing sufficiently well compensated to enable him 
to devote his best energies to his work. 

Mrs. John L. Stewart, South Bethlehem: 

My excuse for taking up a few moments is that I should like to say a word 
for parents. They have been criticized and unfortunately, a large number 
deserve it; if they did not, I am sure we should have this room crowded by 
those who ought to be interested in all these matters so seriously advocated — 
the relacion of their children to the whole of life. I feel that perhaps I rep- 
resent a smaller group of parents who feel that there is a great deal to which 
they do give their consideration from the standpoint of the child and in 
fitting him for living. We have heard that there are a great many things 
that are wrong and we know that there are in this civilization. The best 
perhaps that we can say is that they have come about from the fact that we 
are living in an industrial age to which we have not become accustomed; 
we have not fitted ourselves for these new conditions. We realize that the 
home is not capable, the discussion proving it to have broken down in a 
number of instances, and the school also seems unable to meet the problems. 
The children leave the school physically and mentally unequipped to do what 
is necessary, and society does not seem to have considered that anything is 
wrong. 

We have had a great many excellent suggestions made during this Con- 
ference, both from the standpoint of the physicians and from the standpoint 
of the teacher. We feel that all these suggestions are good and that they are 
going to make the whole life of the child better; but would it not be wise to 
ask ourselves at this point whether there isn't some very radical thing that we 
should consider at this time? The children of most homes have only the 
school for their guide; that is, the school seems to be the only thing that 
comes between them and what is wrong in many instances. We think 
especially of all the foreign population we have here and ought we not to ask 
ourselves very seriously whether the school really could meet the needs, 
even if it should adopt all these suggestions? I feel that we ought to go to 
the bottom of the situation and look at the matter in a different way; if we 
did we would see that we have been regarding the school from the standpoint 



1 66 

of the book and we should rather regard it from the standpoint of the play- 
ground. The natural life of the child is play. Physically we know that we 
cannot produce the best individual if we shut him up in a building four, 
five or six hours a day and we cannot have the best even if the ventilation is 
perfect. We ought to go seriously into the question from the whole standpoint 
of conditions permitting of fresh air and the natural environment of the child 
which is supervised play and so arranged that the whole life — physically, 
mentally and morally — is viewed and perfected from that starting point. 
Fortunately we do not have to think that out unaided ; some one has organized 
a school system in Gary, Indiana, with play as the keynote. I cannot help 
feeling, without any criticism whatever, that a great deal of our school money 
is wasted, and this means a terrible waste of youth, due largely to the fact 
that the schools are losing their opportunities. We ought to go away from 
here with the determination to study this new system which emphasizes the 
play element, with the view of introducing it in all of the towns of this great 
state, as one way of meeting these conditions. 

Mr. N. M. Emery, Lehigh University: 

The visiting members of the Academy may be interested to know that at 
Lehigh University we are paying proper attention to physical education. 
Three hours a week are required of every student during the entire four years 
of the course. This work is necessary for obtaining a diploma and also counts 
scholastically at the end of each term in determining whether the student 
meets the minimum requirement for remaining in college. An interesting 
feature is that the matter was considered by a joint committee of the faculty 
and of the student body and that the system was recently put into operation 
at the unanimous request of the students. Those connected with the uni- 
versity are not only expecting to see increased physical efficiency but they 
believe the system will have a beneficial effect on the scholastic standing 
of the students. 

Miss Sara Phillips Thomas, Philadelphia: 

The cause of the high cost of living is largely an agricultural one. The 
solution of the question is that the farmer must apply more scientific knowl- 
edge along agricultural lines, practise more intensive farming in order to 
increase production, and schools must teach agriculture; also in this con- 
ference on the conservation of children, I think there ought to be a place 
where the attention should be directed to the effect upon women and children 
caused by the entire disregard of climatic conditions shown in the dress of our 
20th century women, viz., that of low shoes and summer garments worn 
during our winter months. 

Supt. E. E. Kuntz, Lansford, Pa: 

I believe we make a mistake in allowing children to go to school as young 
as we do, that is, the minimum age of six years. I think a good work for the 



167 

legislature to do would be to raise the age at least a year or make a provision 
that for the first year children have half-day sessions only and that they shall 
be under the care of the parent or the home for the other half day. They 
should be outside and in the fresh air. It would be advisable if we could 
have those provisions made by which we could give them the games and 
physical exercise necessary for strong childhood. We know how restless 
children of five or six years of age are. To be at work in the school-room for 
five or six hours a day is cruelty to childhood. A few years ago in my district 
an opportunity was given me in the primary grades to put into execution 
the half-day sessions. I had half of the school in the forenoon and the other 
half in the afternoon. I am safe in saying that we had a better standing in 
our primary grades at the end of that year than before or since. But here 
is our trouble — since we have more room — those parents who do not want 
to be bothered with their children at home, ask if we are going to have half- 
day sessions, wanting, of course, the whole day sessions. The desire of some 
parents to be rid of their children at home by sending or wanting to send 
them early into the primary grade is a great mistake. If we could give the 
children more of physical culture and less mental cramming, I think we would 
accomplish more good for public school children. 

Dr. H. B. Bums, Pittsburgh: 

As the official in charge of the work of School Medical Inspection in Pitts- 
burgh, I want to correct an impression that may have been received from 
Dr. Savage's paper. His statement that the low physical standard of the 
two classes in question was because or indicative of the inefficiency of 
Medical Inspection in Pittsburgh is misleading and unsustainable. 

The medical examination of the school children in Pittsburgh did not be- 
gin until June, 191 1. No student, therefore, in the two classes referred to 
by Dr. Savage, or any other class at Carnegie, had ever been the recipient 
of any such examination, having been admitted to the Institute of Tech- 
nology before the work of School Medical Examination was inaugurated in 
Pittsburgh. 

It is regrettable that Dr. Savage did not take the time to inquire as to 
this before making a statement which practically charges the Pittsburgh 
School Medical Inspection with responsibility for a condition which existed 
previous to its birth. 

Dr. L. L. Button, Rochester: 

I believe that it would act for the advancement of hygiene, both general 
hygiene and sex hygiene, if there should be two large toilets in each school 
building, one for boys and one for girls. These rooms should be in charge 
of a carefully-selected man and woman. The rooms should be equipped with 
liquid soap and paper towels, and such other usual conveniences that school 
toilets generally fail to offer. This supervision and provision would, I be- 



i68 

lieve, not only teach habits of personal cleanliness, but also prevent the 
acquisition of much bad sex misinformation. 

In the matter of eugenics, it seems to me that hygiene, properly taught 
in the present school generation, will have a most salutary effect later on 
when these children become adults ; for, as I see it, the greatest good in eugenic 
advancement comes from within thorough hygienic instruction, and not from 
without by means of external pressure, such as is exerted by legislation. 
Such measures do good, but it is only when they are voluntari ly accepted and 
lived up to that the best kind of good results. The attempt to force eugenics 
upon the unreceptive fails to develop the very qualities most essential for 
good, namely, the will and the intelligence to do the right thing. These I 
believe can only come by education, and not by legislation. 

Mrs. Clara P. H. Stilwell, Philadelphia: 

We have heard so much about what the teacher should be, that I cannot 
but say a word for what the teacher is. In our schools we find very many 
men and women who are self-sacrificing, who are greatly in earnest, and the 
largest factor coming into the life of the child. I think the only reason why 
the majority of these teachers do not measure up to the standard which you 
are asking of them is, because they have not had the opportunity for the 
preparation which they most gladly and willingly would have embraced had 
it been within their reach. 

It has been my privilege within the last two years to go into 150 public 
schools in the city of Philadelphia, and thus I have some knowledge of what 
the teaching force is in that city at least. Going into that part of Phila- 
delphia where there is almost altogether a foreign population, I have many 
times had little children greeting me with "How do Teacher," "Hello, 
Teacher," and on several occasions they have rushed up to me in tears, with 
an appeal for help in some childish difficulty. Why? Because seeing a 
woman in appearance and manner different from those about them, they 
thought she must be a "Teacher" — one sure to be both kind and wise. 

Dr. Seneca Egbert, Philadelphia: 

I feel that not enough attention has been given to the matter of play- 
grounds to-day. This is a feature of our public school question. It seems 
to me that it is bound to become associated with our medical inspection, 
and that the school medical inspector will some da5' prescribe for those 
children who need it so many hours in the playground per day, just as he 
now advises glasses, dental care, etc. Half- instead of whole-day sessions for 
primary 7 children have been spoken of. I believe myself that we start our 
youngsters too early into school life and that the sessions are too long for some 
of the younger pupils. If we had abundant playgrounds so that the small 
children could spend part or half of the school hours in them it would be an 
admirable arrangement. I think an important thing hereafter will be to see 



169 

that schools are provided with playground facilities, either close at hand or 
readily available. 

Dr. Florence H. Richards, Philadelphia: 

I should like to ask Dr. Storey how long a time he gives the pupil to have 
his teeth attended to, and whether, if this is not done promptly, there is any 
way by which he can force the parent to cooperate with him ? 

Dr. Storey: 

We plan to give each case sufficient time to secure the services of the 
regalar family medical or hygienic adviser, but we also plan to waste no time 
in useless waiting. Whenever it is possible to secure the desired treatment 
in such a short time, the individual is required to report on the day following 
his examination. If the service of a dentist or a physician is involved, we 
always plan to allow a Saturday or a holiday to intervene in order that the 
boy may have sufficient time to make a regular visit. 

In those cases where treatment is promised, we wait a reasonable time — a 
month, or until after the summer vacation — and then inquire as to the ful- 
filment of the promise. 

Dr. Elizabeth L. Martin, Carnegie Institute of Technology: 

This is the fourth year that there has been regular medical inspection in the 
Margaret Morrison Carnegie School for Women; and as the first class under 
observation for three years graduated last spring, it was interesting to note 
the improvement. 

I make every fall a physical examination of the entering class besides the 
regular measurements which are taken by the instructor in physical training. 
A record is kept of the condition of each student at the beginning and end of 
each school year. All defects are noted, and, of course, appropriate advice 
given for the improvement of such cooperating as far as possible with the 
family physician. 

Agreeing with Dr. Savage's observation of the men, I found a very low 
standard of nutrition among the women. On admission to the school, the 
191 1 class, 62 in number, had only 37 per cent, of their number who could 
be rated as normal in respect to their nutritive and nervous condition. This 
class graduated with 49 members, 61 per cent, of whom were rated as being in 
good condition, 32 per cent, as fair and only 6 per cent, as poor. 35 of the 
49 women showed definite improvement which was especially marked in 17 
who were distinctly poor on admission to the school. 

It is very gratifying to see the improvement in girls who had failed in other 
schools on account of ill health and who graduated last year and are now 
doing excellent work. I do not feel that the credit for this depends entirely 
on the medical work nor upon the work in the gymnasium, for the object 



170 

of this school is to train women for "living" and the cooperation with other 
departments is of the utmost importance. 

When girls are studying sanitation, cooking and the chemistry of foods in 
connection with the principles of physiology, it is comparatively easy to gain 
their cooperation in right living. I believe one's influence is tremendously 
increased when you can tell them "why" certain rules should be obeyed. 
And this is simplified by beginning the teaching with a study of the conditions 
necessary for all living things. I have always felt that my work as school 
physician would be greatly hampered had I nothing to do with the teaching 
of the first principles of hygiene. 

Dr. Helen C. Putnam, Providence: 

As the discussion seems to be gathering up various omissions in the con- 
servation of school children, we should go on record as including one funda- 
mental alteration in our schools that has been advocated by several writers 
during the last 20 years and recently by no less a personage than the Specialist 
in School Hygiene and Sanitation of the United States Bureau of Education, 
Dr. Dresslar. It is that school houses should be built where they can have 
several acres of land around them. This means for cities building them in the 
suburb, with perhaps or probably free municipal transportation — that we 
hope for us all some day. This is very like what some rural communities 
are doing for their "consolidated schools," and is what many private schools 
do for even children of kindergarten and primary ages. These have already 
demonstrated the practicability of transporting pupils between school and 
home. 

The need for schools to be in an environment of health, nature and beauty 
is imperative. For health alone there are reasons enough. Fresh country 
air coming in windows, doors and ventilating openings will do much to solve 
the problems of cleanliness and to improve our vital statistics. The peace 
of bird songs and rustling leaves and country roads will help. The sur- 
rounding acres would furnish playgrounds and school gardens, while con- 
stantly educating in primeval phenomena and giving glimpses of the in- 
finite from which the environment of city wards cuts off all knowledge. To 
develop human souls between brick walls and stone pavings, among crowds 
and police means a more serious loss to character than the men who make 
such cities appreciate. It is not necessary. Already Boston has given more 
or less extended study to the matter, which is the first step toward its realiza- 
tion. 

If this Conference were to formulate but one resolution, I am confident 
that the wisest — because it would go furthest toward solving many prob- 
lems in conservation of children — would be one urging study of the feasibility 
of locating every school building in a small park for children's use, with free 
transportation if necessary. I am not sure that it would cost more than our 
present meagre yards in the midst of cities. In the long run — the building 
of a nation — it will do much to save us from bankruptcy. 



171 

Dr. W. S. Cornell, Philadelphia: 

It has been said that one of the great faults of our medical inspection is 
the making of statistics. However, there are a few things that we have done 
in Philadelphia worth mentioning. In the first place, about glasses. We 
have a city oculist who treats two or three thousand children each year. 
Then we have an arrangement with three or four reputable opticians who will 
supply glasses for one dollar a pair to any child whose parents are unable to 
pay more — the child who gets his glasses for nothing is very apt to break 
them. We have a dental clinic at City Hall morning and afternoon and 
another dental clinic at one of the public schools. My recollection is that 
from six to nine hundred have been treated at City Hall since the beginning 
of the year. 

The greatest difficulty attending the open air schools is the item of expense, 
this being $100 compared with $30 for the ordinary child. I shall certainly 
bear in mind the suggestion of Dr. Egbert concerning playgrounds. I cannot 
see the practicability of having the public schools in the suburbs. We would 
do well to follow the plan of the Catholic Church in Philadelphia and build 
our schools as they do their churches in a beautiful place beside a public 
square. If we had one or two schools in Philadelphia along the park it would 
be a great benefit to the children. I think too often parents feel that the 
children cannot walk more than about four blocks to school. 

Dr. H. M. Bracken, St. Paul: 

We have had this subject presented from the standpoint of public health 
and from the standpoint of the educator. A short time ago an educational 
body committed itself to the policy of recommending that this work should 
be carried on from the educator's point of view. It seems to me unfortunate 
that any body should commit itself to a definite policy for I think the con- 
ditions depend largely upon the locality. In certain places it would certainly 
be better at the present time to carry on the so-called medical inspection 
of schools under the Board of Education. In certain other places it would be 
impossible to get inspection under the Board of Education. It is necessary 
in the country districts that public health and school inspection should be 
carried out together and under such conditions, medical school inspection 
should be under the health department rather than the board of education. 

I think it is too early for us to commit ourselves to any one policy. Dr. 
Storey put up a strong argument for the educational side, but I think you 
will all agree with me that Dr. Sto/ey's work is Dr. Storey's work, not the 
educational department's work. 

It may not be wise to move all of our city schools to the country, but it 
seems to me a mistake to locate our open air schools in cities. There is only 
one place for an open air school and that is in the country. In England you 
will find that the children go long distances. In some instances at least 
they are carried to the end of the tram line, and then still farther in some other 



172 

form of conveyance. Often the second conveyance fails to meet them and 
they then have to walk. You speak of expense in England, the tram lines 
do what the street car lines ought to do in this country ; they carry the children 
free. 

Supt. Halliday R. Jackson, Mauch Chunk, Pa. : 

I should like to present some of the problems of the smaller districts. Our 
school board voted for medical inspection, and we have had twenty minutes 
of medical inspection for 500 children. You will say we should have written 
to the health department. We did, but the machinery moves very slowly. 
The teachers carry on a cursory examination and when we have found defects 
in hearing or vision our trouble has only commenced because in the country 
we do not have the hospitals to which we can send the children. One diffi- 
culty is that the glasses are secured from wandering oculists who give what 
they have and not what is best. Another of our difficulties is the problem 
of ventilation. 

You will find installed in many of our smaller towns systems of ventilation 
with elaborate rules, requiring for example that the windows shall always 
be kept closed. In some places the sashes are screwed down. The new State 
Board of Education will probably take care of new buildings but many pupils 
and teachers will suffer through the older buildings. 

It would be a splendid thing for the smaller communities if this body could 
spread among the doctors a feeling of responsibility for child life that would 
remove many of the compromising statements such as "I think you can get 
along under the present conditions" or "it is not absolutely necessary that 
this system or practice be changed." 

The doctor occupies a vantage ground in the small community and if he 
insists that defects be attended to, much more is likely to be done than if he 
merely suggests that "it would be better or ideal to make the change." 

Dr. Storey closes : 

I believe that the things we have done may be accomplished by any group 
of men equipped for such work, provided those men possess tact, patience 
and perseverance. I believe, too, that the systems I have put into operation 
will work anywhere with certain necessary local modifications. The larger 
problem is a complex one. The rural district is one problem, the small town 
another, and the big city another. The general plan for all localities may 
be the same, but the details of local application must necessarily vary. 

I should not like to leave the impression that I do not believe in the ab- 
solute final authority of the Board of Health in matters related to com- 
municable disease. Whatever medical inspection may do in the schools, 
the Board of Health is finally responsible in all cases of infectious and com- 
municable disease. The school department covering medical inspection 
should refer all such cases directly to the Board of Health. 



173 

I should like to point out certain disturbing influences which will operate 
against the satisfactory development and the best success of a system of 
medical inspection anywhere: (i) Educational conceit in the school man; 
(2) educational ignorance of the medical man; (3) lack of tact on the part of 
both. For the two to get along there must be some feeling of mutual re- 
sponsibility and mutual respect. Each must realize the need for and the 
value of the help of the other, regardless of who is in final authority. 

Again, the question of the influence of politics is a serious one. So long as 
politics may have a determining relationship to medical inspection, so long are 
the chances of establishing a successful and enduring system relatively small. 

What we can and must do is to lay down the general principles along which 
medical inspection shall be developed and then hope that in each individual 
community there will be secured the best available educational, medical and 
public-spirited help, so that the local system may be developed to fit the 
conditions as they there exist. 



XVIII. 

THE RELATIVE PHYSICAL ADVANTAGES OF SCHOOL 

LUNCHES IN ELEMENTARY AND SECONDARY 

SCHOOLS. 1 

By Ira S. Wile, M.S., M.D., New York. 

The general trend of present human progress is distinctly along 
the line of the conservation of field and forest, mine and stream, 
and at last attention is being adequately focused upon the con- 
servation of childhood. With compulsory educational laws 
existent throughout the States, the responsibility of the States 
for the safety and protection of childhood has been increased. 
To compel a child to go to school by law is to assume the responsi- 
bility for the care of the child during the period for which the 
child is within the custody of the educational authorities. Dr. 
Harrington has stated that "Education must consider the student 
as the subject of its teaching." To spend all the stress of thought 
upon curriculum, school buildings, school gardens, music and 
art, is neglecting the most important phase of the educational 
problem, namely, the child who is to receive the education. In 
the broad conception of educational institutions, the curricula 
and the teachers are far less important than the problems of 
securing fresh air and good food for the boys and girls during the 
school age. 

Medical inspection as related to the public school system makes 
note of many symptoms which are apparent among the children, 
but all too frequently fails to get down to the causative factors 
responsible for them. Preventive medicine demands a knowledge 
of causes in order to assure efficient prophylaxis. The intellectual 
development of children and their physical development are 
inter-dependent and do not represent isolated phases of child 
nature. A sound body and a sound mind are closely interrelated 
and are not mutually exclusive. It is in the interest of the edu- 
cational system to develop the students in those phases of life to 
which the home gives inadequate attention. If as a result the 

1 Read at the Conference on Conservation of School Children, Lehigh University, 
April 4, 1912. 



175 

school often seems to overlap the functions of the home, it is in 
the best interests of both the home and the school. 

No one would deny that in any system of education the point 
of view should be such as to secure the greatest good to the 
greatest dumber of children. Taking New York City, for example 
in the yW 1910, there were in the elementary schools 693,246 
children ^liile there were in the secondary schools only 50,902, 
of which number 31 per cent, failed to finish their course. It is 
striking to note that in the elementary schools only 31,341 chil- 
dren graduated, while in the sixth grade there were 68,514. In 
the special classes among the elementary school children there 
were 1484 defective, 432 cripples, 215 tuberculous, and 62 anemic 
children. It is all well and good to provide adequate attention 
for those abnormal children and to supply them with food and 
fresh air, as well as the mental pabulum, but it seems a much more 
rational procedure to give the same opportunity for the preser- 
vation of health to the normal school children instead of placing 
a premium upon ill-health. 

In the entire school system of New York City, only 3.42 per 
cent, were over 16 years of age, but there were 175,000 children 
over 12 years of age in the fourth grade and above, 41,000 of 
them being in the eighth grade. The relation between mentality 
and good health has been well established. Porter, from St. 
Louis, has shown that well developed children take a higher rank 
than less developed children of the same age. The purpose of 
education is to fit children for life; and the knowledge that they 
may acquire and the use that they may make of it are equally 
dependent upon the health of the child during the course of 
education. 

Puberty is a period of general acceleration of growth. There 
is an increase of height, of weight, of strength; there is a modifi- 
cation of the nervous system with the development of the emotional 
side of the child's nature, and a susceptibility to impressions 
such as occurs at no other period of life. In addition to this, 
puberty forms the period of the development of the sexual char- 
acteristics which bring to bear upon educational problem all the 
variations that may come from the dominance of sexual emotions 



176 

and the manifestations of sexual development. Physical edu- 
cation must embrace more than a question of muscles ; it involves 
brains, sex life, and general stability. It is not a question as to 
whether a muscle is hard or soft, or short or long, or thin or broad, 
but it is a question as to the general physical efficiency of the 
child, and this involves its mental as well as the ordinarily 
termed physical attributes. The opportunity to affecc the pu- 
bertal development of the children is given only during the pre- 
pubertal period, and this represents the period of greatest activity 
of the schools, for the average age at graduation from the elemen- 
tary schools of New York City is fifteen years. 

Superintendent Maxwell in his Twelfth Report states: "Pro- 
vision should be made in all schools for supplying fcod at cost 
price to the pupils in the middle of the day." This, in a way, is 
an acknowledgment from the head of the school system that 
there are many children for whom food is not available at home 
during the very period for which provision is made in the work 
of the day for them to go home for food. Educators well ap- 
preciate the necessity of full stomachs as a prerequisite to se- 
curing full minds. Nourishment supplemental to that of the 
home is now being supplied to cripples, anemics and subnormal 
children for curative purposes. It is far more wise to extend the 
institution of making a food supply available to the elementary 
schools for the purpose of preventing the physical, mental and 
often moral break-down of the children during the period of 
elementary school life. Adequate and well selected nourishment 
is essential to the well-being of children. The effect of food, as 
well as fresh air, may be readily understood from the experience 
of the anemic class of Public School 21, New York City, where 
during 10 weeks the average gain in weight was 3V2 lbs. In 
Boston, 18 pupils gained on the average 4V2 lbs. in three months 
with supplemental nourishment in a fresh air class while their 
total absences for a period of three months were reduced from 
583 to 39. 

In every community there are many poorly fed children whose 
malnutrition is evidenced in part as anemia, or in enlarged glands 
or in susceptibility to contagious diseases. For children of this 



177 

character supplementing the home feeding is exceedingly desirable. 
There is no intent to suggest that free lunches shall be provided 
for public school children, as this would merely serve to relieve 
the family from the responsibility of feeding the children. Avail- 
able lunches, however, are a boon to the family and a necessity 
in order to supply adequate food for the many children who can- 
not secure it at home. The responsibility of the family is not 
lessened, inasmuch as the available lunch is not given gratui- 
tously, but is sold for a small sum, and the responsibility of the 
parents is heightened by impressing upon them the necessity of 
having their children take advantage of the lunch available at 
the school. 

Physical training at the present time takes cognizance of the 
general development of the children and even goes so far as to 
give marks for posture, chinning and exercises of various kinds. 
Motor training, however, is not merely muscular, but has nerve 
stimuli for whose prompt action good nutrition is essential. It is 
well known that in the course of training of athletes neuro-muscu- 
lar planes are developed through superalimentation. Endurance 
is not independent of food, and the physical training of children 
of the elementary schools requires for the successful development 
of the children an abundant, varied and sufficient food supply. 

Much attention has lately been given to the question of proper 
dentition. It is a striking thought that the permanent teeth of 
children practically are developed during the period of elementary 
school life. It might well be said proper food means proper 
teeth. As has been suggested "If children could be sent to a 
chewing school as they are now sent to a kindergarten there 
would be a marked improvememt in the race." 

Dentition may be delayed or impaired by inadequate nourish- 
ment. The lack of lime salts in the daily dietary in the home is a 
large factor in early decay. The value of tooth brush classes for 
children whose permanent teeth have not yet erupted arises from 
the congestion produced in the gums, which adds to the general 
nourishment of the teeth in process of development. Good 
teeth depend upon adequate nutrition and certainly adequate 
nutrition is dependent upon the teeth. 



1 7 8 

Malnutrition is a large factor in the production of tuber- 
culosis, adenitis, mental defects, anemia, defects in vision, 
protracted convalescence from disease, and impaired resistance 
to the infectious diseases. The economic and educational 
value of nutrition may be appreciated from the fact that 
children with defective teeth take 8V 2 years to go through 
8 grades of school, while children with enlarged glands require 
9.2 years to go through the same grades. It hardly seems neces- 
sary to comment upon the rate of illness as it occurs among 
children in the primary schools and the secondary schools. A 
large factor in the retardation of children in their progress through 
the elementary schools is the absences due to ill health, and a 
large part of this ill health is due to malnutrition of the child. 

I recognize the fact that the home environment cannot be wholly 
remedied as far as sanitation, ventilation, facilities for sleeping 
and rest are concerned, but supplemental feeding will strengthen 
the home so as to lessen the dangers from the other unhygienic 
conditions. The school luncheon may supply foods yielding 
nutrients deemed necessary for growing children, but which are 
not contained in the home dietaries. With the careful adjust- 
ment of the feeding conditions not alone does physical growth 
ensue, but mental development must follow. Halleck has epi- 
grammatically stated the problem by remarking that if a child 
have a skim milk diet, he will have skim milk thoughts. 

Physical education must take account of factors that are re- 
lated to physical development, and if one recognizes the wisdom 
of feeding the anemic, the tuberculous and the crippled, is it not 
equally desirable to feed the brothers of these same children to 
lessen the likelihood of their physical deterioration? 

The Principal of one of our large anemic classes has called 
attention to the great mental improvement of the children in 
that class, in addition to their physical development. He notes 
that the children are better able to work in the late morning 
hours and in the afternoon than when they came to school. Miss 
Farrell, who has had charge of the un-graded classes, attests the 
advantages accruing to mental defectives who are returned to 
their grades after proper feeding. Superintendent Maxwell in 



179 

his Tenth Report states that 60 per cent, of the defectives suffer 
from malnutrition. As an economic measure of reducing the 
number of special classes, it is much cheaper to supply school 
luncheons than to provide separate buildings and special teachers 
and in part disorganize the work of the school. Lord Dufferin 
has remarked that "our mental functions, our memories, our 
attention, our power of continuous application are even more 
dependent for vigor and vitality on the general condition of our 
health than is the play of our muscles." It becomes imperative 
to supply the foods essential for improving the general vitality 
of our school children in order that the educational system may 
be made most effective in giving the education for which they are 
established. 

Underfed children are more vulnerable to disease, more sus- 
ceptible to protracted colds and bronchitis and tonsilitis; are 
more likely to suffer from infectious diseases which occasion 
prolonged absences from the school and frequently lessen the 
efficiency of the school system. Weak musculature, sluggish 
circulation, chorea and functional disorders of all kinds are far 
more common among the underfed than among any other type 
of children. The recognized underlying factor in chorea is a 
neurotic constitution, anemia, and some severe disturbance of 
nutrition. The New York Committee on the Physical Welfare 
of School Children found 26.2 per cent, of chorea in children 
suffering from malnutrition as opposed to 3.6 per cent, for the 
1400 children studied. This same Committee found that mal- 
nutrition occurred to the extent of 10.4 per cent, among 1400 
children in October, and 12.9 per cent, in April among 990 children 
reexamined. This shows the deterioration of children during the 
course of school year due to inadequate home feeding. 

School luncheons in secondary schools really exist as a matter of 
convenience, and can in no way be regarded as part of the health 
question. A lunch room is provided for the elect of school chil- 
dren who come from homes better provided with the good things 
in life, and from families whose standard of living and income is 
such as to permit the continuance of the children at the school 
for a longer period of time. 



i8o 

At the present time we hear considerable regarding ventilation 
in the public schools, and there is a general movement to secure a 
lower temperature in the school rooms. Among well fed children 
it is easier to secure the reduction of temperature. It is practi- 
cally an impossibility to place children in sedentary postures, in 
open air classes, without supplying a larger amount of food in 
order to supply the requisite amount of bodily heat that is es- 
sential to offset the climatic temperature. No open air classes 
at present exist without supplemental feeding. School lunches 
insure better digestion of food and less bolting. There is no hustle, 
no fear of lateness or running to school with articles of food to 
be eaten on the way. It is a practical measure for eliminating 
the unwholesome diets which are all too frequently secured from 
the pushcarts by those who are unable to receive a lunch at home. 

Even the question of fiat foot is not always a question of muscle, 
as much as it is a question of relaxation from under-nourishment. 
It has been estimated that 40 per cent, of our children in high 
schools suffer from flat foot, and it is fair to assume that a still 
larger proportion of this difficulty is to be found among the chil- 
dren of the elementary schools who are 12 times as numerous. 

The purpose of the school lunch is not to satisfy acute hunger, 
but to serve in part to relieve the chronic underfeeding of school 
children. It is rather difficult to secure figures showing the 
amount of under-nourishment that there is among children in 
the elementary schools, but it is fair to take the statistics gathered 
by various observers. For example, Gershel has studied Jewish 
children, which figures are germane to New York City, inasmuch 
as there are over 650,000 Jews in New York City. He shows 
that the dependent Jewish boys grow 14.86 inches from their 
5th to their 15th year, while Bowditch shows that the Boston 
boys grow during the same period 20.8 inches, while according 
to Porter, St. Louis boys grow 18. 1 inches, and the English 
Anthropological Committee find 21 inches, the boy's growth 
during this period of life. At five years of age the average Jewish 
dependent boy is 1.6 inches shorter than Boas, average; at ten and 
a half years he is 1.68 inches behind; at eleven and a half years, 
3.40 inches; at fourteen and a half years, 5.58 inches; and at 



i8i 

fifteen and a half, 7.9 inches behind the average for boys of the 
same age according to Boas. 

Gershel accounts for this by stating that during "the important 
age of puberty he had undergone many sufferings and privations 
at an age when freedom and proper nourishment are absolute 
essentials." The increase of weight is an excellent index of 
health as a general rule. It has long been known that boys of 
the favored classes are heavier than boys of the same age coming 
from the industrial classes. Imperfect nutrition may retard 
growth and weight in itself is not a full index of good health. 
Burk has published the study of 68,000 children from Boston, 
St. Louis and Milwaukee, whose average increase of weight was 
5 lbs. a year to the 12th year. At twelve and a half it was 6.2 
lbs., while Gershel's Jewish dependents increase 4.87 lbs.; at 
thirteen and one-half years was 7.9, Gershel's 4.39; at fourteen 
and a half years 10.4 lbs., Gershel's 4.46; and at fifteen 
and a half years 12.2 lbs., Gershel's 7.34. The retardation of 
weight for the dependent boys is especially noticeable from the 
tenth to the fourteenth year. The general gain in weight that 
may be brought about by a school lunch has been shown by the 
experience of the New York Lunch Committee where in three 
months there was an average gain of io 1 / 2 oz. for those children 
adjudged to be suffering from malnutrition who took the school 
lunch as opposed to 3 2 / 5 oz. for the same period of time among 
the children also adjudged to be suffering from malnutrition but 
who failed to take advantage of the lunches at the school. The 
degree and underweight of the children adjudged to be suffering 
from malnutrition may be appreciated by the fact that out of 
262 children only 44 were at or above the normal weight for their 
age. 

The economic status of high school students according to the 
U. S. Bureau of Education, shows that only 16 per cent, of the 
children in the secondary schools come from families with an 
income below $750 per annum. This was based upon the reports 
from 1473 schools which investigated the first 25 students in 
their Freshman classes. The social status in our elementary 
schools reveals a far different economic standard. 



182 

At the present time elementary lunches exist in almost all 
civilized countries with the exception of the United States. In 
England, Denmark, Sweden, France, Italy, etc., the school 
lunches are regarded as educational measures. The educational 
advantages arise from the general improvement in the physical 
condition of the children taking the lunches. Of 2051 children 
examined in two of our New York schools, 283 or 13.3 per cent, 
were said to be suffering from malnutrition. We found also that 
10 per cent, of the mothers of the children worked outside of the 
home and consequently were not home at noon to offer food to 
their children. From an analysis of the dietaries used in the home 
for the children 71 per cent, of the families under observation 
were regarded as supplying insufficient nourishment for their 
children; 64 per cent, of the malnutrition cases came from families 
with an income below $16 a week. The New York Committee 
on the Welfare of School Children found that 41 per cent, of 
malnutrition of children arose in the children from families with 
incomes of less than $16 a week. 75 per cent, of the children 
taking luncheons came from families with incomes under $16 a 
week. During 1909 and 1910, 252,254 children were given 
thorough physical examinations. Malnutrition was found in 
8054; chorea in 821 ; tuberculous nodes in 997; pulmonary diseases 
in 1964; orthopedic defects in 1728; defective mentality in 691 ; 
a total of 14,255. Of defects of the teeth there were 135,186. 
Taking this proportion of defects found in only one-third of the 
children of the elementary schools, and applying the same ratio 
to the entire number of children in the elementary schools there 
would be 42,765 children in elementary schools with these few 
physical defects exclusive of the dental disturbances. This 
represents almost as many children as there were in all the sec- 
ondary schools of the city. 

To promote physical growth and mental development are but 
two sides of the same problem. To accomplish the greatest good 
to the greatest number the most stress must be laid on the growth 
and development of the children during the pre-pubertal period 
or the years given to life and work in the elementary schools. 
As a factor in medical education the dietetic side of the child's 



183 

life demands attention. For this reason an available school 
lunch is more essential in the elementary schools than in the 
secondary schools. 

230 West 97th Street. 

DISCUSSION. 

Dr. I/. L. Button, Rochester: 

The poorly nourished child is not the only one that we in Rochester find 
can be helped by feeding. That the incorrigible child also behaves much 
better when fed, is also found to be a fact. 

Dr. Baker, West Chester: 

I think a question that might come before this body is, what shall be done 
with the children in the evening when the mother is not in position to reach 
out with them and give them the entertainment they want? The rich mother 
is able to do things for the social side of the child. The poor woman feels 
the same need but cannot supply it. When the child does not find this 
entertainment in the home, the dance hall, the moving picture shows and 
conditions that demoralize claim them in the evening. 

Dr. Wile, closing: 

We have a three cent lunch. This pays all the cost of the food and covers 
all expense, except the cost of administration and distribution. For the Irish 
children we have an Irish cook. The Irish will not eat their soup thick, 
and the Italians will not eat theirs thin. Each nationality forms a study 
unto itself. We try to use the materials essential for the children's develop- 
ment. We try to give one-third the amount of food that the child should 
receive in 24 hours. We make the estimate upon the age of a child of ten 
as the older children are getting foods from other sources. Estimating upon 
a basis of 1875 to 1900 calories, we give as a minimum amount, 445 calories. 
We consider first, the palate and second the question of economy. Then 
comes the question of facility in distribution. We have to use the best 
Italian oil— no common cottonseed oil for Italian children. For an extra 
penny the children may get a particular article of food which they wish from 
the extra foods available. With our Italian children we also use the cheese 
products. With the Irish children we tried clam chowder, and plain soups 
leaving in the meat finely chopped. All lunches are paid for either by the 
children or by some charitable organization caring for the family whose child 
is at the school where lunches are available. Some of the youngsters re- 
ceive the lunches in payment for their services during the luncheon period. 
All the steps of the serving of the lunches are taken by the children. 



XIX. 

CLASSIFICATION OF THE FEEBLE-MINDED BASED ON 
MENTAL AGE. 

By A. C. Rogers, M.D., Faribault, Minn., Superintendent of the Minnesota School for 
Feeble-Minded and Colony for Epileptics. 

All who for the first time give attention to the literature and 
treatment of mental defectives are puzzled and confused by the 
lack of uniformity observed by writers and experienced workers 
in this field, both in the nomenclature adopted and classifications 
followed. It is the purpose of this paper to call attention (ist) 
to the present tendency of the authorities to approximate uni- 
formity as to the fundamental conceptions involved, (2nd) the 
long recognized need for some means of comparing feeble-minded 
with normal children at various stages of development, and (3rd) 
recent contributions to child study that seem to furnish the 
foundation required for developing a very satisfactory psycho- 
logic classification of scientific value. 

It is unnecessary to present in full the various schemes for 
classification that have been proposed, 1 and the writer will only 
refer to such features of a few that have gained substantial recog- 
nition and standing in the profession as may be necessary to 
make the situation clear. 

We will consider first the fundamental conceptions concerning 
which there is a very general agreement. The first has reference 
to the general but constant characteristic of the ensemble of 
infirmities that we now speak of as feeble-mindedness, viz., that 
it is mental incapacity from arrested development more or less 
complete, whether the cause is (1) lack of potency in the germ 
plasm from inheritance; (2) interruption of the biologic evolu- 
tion in utero from (a) toxic interference or (b) deficient nutrition ; 
or (3) an arrest of development, more or less extensive, in the 
cerebro-spinal axis after birth from (a) inflammatory processes, 
(b) toxic influence, or (c) deficient nutrition. The mental in- 
capacity varies in different individuals from completeness so that 
the existence is vegetative only, to merely a lack of coordination 
between the affective intellectual and volitional faculties, so that 
the individual is disqualified for harmonious social relations. 



i«5 

The recognition of this constant characteristic is so universal 
that I shall not cite authorities, except to call attention to this 
illuminating statement of Dr. H. B. Wilbur, when discussing the 
possibilities of a pathologic classification. 2 

It should be borne in mind that the essential fact of idiocy is the mental 
deficiency. That the point of interest for us is the degree to which this con- 
dition can be obviated. Furthermore, it is dependent upon physical con- 
ditions, whether physiologic or pathologic, that are chronic or organic — slowly 
produced structural changes, when pathologic — and so, as a rule, beyond 
the reach of remedial means. The sphere of these, when used in the treat- 
ment, is almost exclusively confined to ameliorating the accessory maladies. 

The actual work of obviating the condition of idiocy is an educational one, 
using the term in a broad sense; and if any favorable effect is produced upon 
abnormal organic states, it will ordinarily be through the reflex action of 
properly adjusted mental exercises. 

This clearly separates this group of people from the insane — in 
whom the mental functions deviate from normal after the evo- 
lution of physical growth has been completed. The condition 
is thus recognized as a defect, not a disease. 

The second conception of this condition is that the mental 
incapacity when profound co-exists with and depends upon an 
arrest of physical development — by which the motor and reflex 
activities are deficient or incoordinated — the processes of physio- 
logical evolution in childhood being retarded or entirely arrested. 
The recognition of the interdependence of the mental and physio- 
logical infirmities is important, not only for a sound basis for a 
rational comprehension of the general condition, but because the 
whole system of training of the feeble-minded is based upon it. 
The exposition of this fact and the enunciation of the educational 
principles deduced from it constitute Seguin's great contribution 
to pedagogics, general 3 as well as special. Seguin thus graphi- 
cally depicts the analogy between the normal and the idiot infant. 4 

The majority of young idiots do not differ very sensibly from common 
babies; because the power of both may be expressed by the same verb, they 
cannot. But to-morrow the well infant will use his hands, the idiot will 
allow his to hang in half flexion; the first will move his head at will, the second 
will toss it about; the look of the former penetrates every day farther than 
the domain of the touch, that of the latter has no straight dart and wanders 
from the inner to the outer canthus - the one will sit erect on his spine, the 



1 86 

other shall remain recumbent where left; the first will laugh in your face 
with a contagious will, the second shall not be moved into an intellectual 
or social expression by any provocation whatever. And each day carves 
more deeply the differential characters of both: not by making the idiot 
worse, unless from bad habits gotten by neglect, but by the hourly progress 
of the other. Idiocy so viewed from its origin is a continuance of the isolation 
and helplessness of babyhood under ampler forms and obsolete proportions. 
Compared unavoidably with children of his age, the idiot seems to grow 
worse every day, his tardy improvement looking like backward steps. With 
his incapacity of action, of expression, of feeling, he makes a sickening sight 
indeed by the side of a bright child entering into the intricacies of life as on 
an open playground. 

As a third conception, we should next note that there has been 
a gradual approach by writers toward a substantial agreement 
in the rough psycho-physiologic grading of mental deficients 
into three groups, and the use of terms by which these groups 
are known. 

The term "idiots" is now universally applied to the individuals 
of the lowest group, who are entirely dependent. "Imbecility" 
applied by Seguin to acquired cases, where some mental develop- 
ment had preceded the final arrest, is now generally applied to 
the intermediate grade. 

There is less general agreement as to the proper term by which 
the upper group shall be designated. In England the term 
"feeble-minded" is applied to the latter by the Report of the 
Royal Commission of 1904 when considering adults; and "men- 
tally deficient children" when considering non-adults. 

The terms Aments, 5 Mental Defectives, 6 Mentally Deficient 
Children 7 and Feeble-minded 8 ' 9 are variously used for the whole 
class. In the United States the three groups are generally recog- 
nized, the lower third as idiots, the intermediate grade as imbeciles, 
and the upper third as high-grade feeble-minded (lately, morons), 
the term feeble-minded being applied generically to the whole 
class. 

Ireland, who put especial stress on the value of a pathological 
classification, says: "Mental Deficiency is the most serious of 
the symptoms or consequences of the diseased conditions. It is 
of great importance that the degree of mental feebleness should 
be defined. Hence, the necessity of psychic definitions like 



i8 7 

idiot, imbecile and feeble-minded, indicating three degrees of 
mental obtuseness." 10 

Bianchi, 11 who terms the general condition Phrenesthesia, says: 

We cannot free ourselves from the traditional nomenclature of idiots, 
imbeciles and weak-minded, adopted now for a long time by the majority 
of writers; but it must be distinctly understood that we do not mean to signify 
by these names well distinguished groups, but simply strong differences of 
intermediated and extreme degrees of arrest of development. 

Barr's classification 12 differs more in appearance than reality 
from the tripartite scheme, using the terms Idiot, Idio-imbecile, 
Moral Imbecile and Mentally Feeble. Admitting that it would 
not be difficult upon establishing some uniform standard — to 
which all would subscribe — to make quite a number of groups 
of feeble-minded differing essentially in mental capacity, and, 
while the American workers have recognized the apt naming of 
a small group as "idio-imbecile" "improvable in self-help and 
helpfulness, etc.," the author evidently only intended it as a 
sub-group. Again, whatever one's view concerning the scien- 
tific basis of the term "moral imbecile," and much can be said in 
its favor as yet, though Fernald's term "Defective Delinquent" 
is preferable, as adequate without raising the other question — his 
place in the intellectual scale should first be fixed; that is, he 
would be first an imbecile or a high-grade feeble-minded (Moron) . 
Barr's "Backward or Mentally Feeble" — "mental processes 
normal but requiring special training and environment, etc." — 
really form a very small group, a sub-group of the morons, if 
indeed in the final analysis it would not be found that the class 
to which he refers belongs to the "Retarded" group of the schools 
and educable in the special classes. Thus Barr's grouping, as 
stated above, requires but little adjustment to line up with the 
generally accepted view. 

Tredgold says: 13 

It is essential, both for purposes of description and administration, that a 
division should be made, and this, on the whole, is best done by means of 
three terms which have long been in use — namely, Feeble-mindedness, Im- 
becility, and Idiocy. To one or other of these degrees we may relegate all 
aments, although it is to be remembered that the boundary lines are by no 



i88 

means distinct, and that the one gradually merges into the other. We may, 
indeed, if necessary, further subdivide each of them into three others, and 
thus describe high-, medium-, and low-grade idiocy, imbecility, and feeble- 
mindedness respectively. 

The Royal Commission of 1904 gave an additional stability 
to the triunal grouping by announcing a set of definitions as 
follows : 

A feeble-minded person (our moron) is : 

One who is capable of earning a living under favorable circumstances, 
but is incapable, from mental defect existing from birth, or from an early 
age, (a) of competing on equal terms with his normal fellows ; or (b) of manag- 
ing himself and his affairs with ordinary prudence. 

An imbecile is : 

One who, by reason of mental defect existing from birth, or from an early 
age, is incapable of earning his own living, but is capable of guarding himself 
against common physical dangers. 

An idiot is : 

A person so deeply defective in mind from birth, or from an early age, 
that he is unable to guard himself against common physical dangers. 

In addition to this, and as completing the series of definitions, 
Tredgold 18 defines the condition characteristic of the whole class 
(Amentia) as: 

A state of mental defect from birth, or from an early age, due to incom- 
plete cerebral development, in consequence of which the person affected is 
unable to perform his duties as a member of society in the position of life 
to which he is born. 

Binet used the terms Idiot, Imbecile and Debile. 

Having made it clear that the leading writers upon this subject 
agree substantially upon the grouping into three classes, and are 
not far apart in the use of the terms, though there has been lacking 
a clear definition of boundaries — it only remains to add that 
there is a natural basis for this grouping from the standpoint of 
speech. Leaving out of consideration the feeble-minded children 
with special speech defects and the language "savants" (rare), 
the rule may be roughly stated in this way, viz., idiots have no 
language; imbeciles are limited to use of words, phrases and short 
sentences, expressions of incomplete and disconnected ideas; 
while morons use language in the complete sentence form, follow 



1 89 

and produce the "flow of speech," limited only by their individual 
ranges of knowledge. 

We will now consider the comparison of feeble-mindedness with 
normal mindedness in children. 

The writer was impressed, while still young in the work for the 
feeble-minded, with the desirability of having prepared a scheme 
showing the natural evolution of the mental faculties of normal 
children with reference to their chronologic age as a guide to 
the grading or the retardation of the feeble-minded. In view of 
the work of modern psychologists along this line and its appli- 
cation to the study of the feeble-minded, to be referred to more 
specifically later — it is of special interest to note the following 
statements, by writers on this subject. 

Speaking of the high grade, Down says: 14 

The test which I have found most useful is one suggested in the first instance 
by Dr. Charles West. In any given case we have to ask ourselves, can we in 
imagination put back the age two or more years and arrive thus at a time 
perfectly consistent with the mental condition of our patient? If he be a 
backward child, we shall have no difficulty in saying what period of life 
would be in harmony with his state. If, however, he be an idiot, there is 
no amount of imaginary antedated age to which the present condition of the 
child corresponds. 

Shuttle worth says: 15 

The best estimate will be obtained by comparing the patient with a normal 
child of similar age. Thus tested, a boy of ten will sometimes be found on 
an intellectual level with the ordinary child of five. 

Duncan and Millard state: 16 

"It is a very striking method of showing the mental deficiency of a member 
of any one of these classes to compare its mental gifts with those of children 
of perfect mind at younger ages. Thus a boy of the fourth class, 17 aged eight- 
een, may not have greater mental power than a perfect child of four years; 
he is to all intents and purposes four years old, and dull for his age. An 
idiot of the second class, of eight years of age, may not be more than eight- 
een months old , when compared with normal children, while the gaiety and 
spontaneousness are wanting." 

We will now consider the recent contribution of psychology 
to the problem of classifying the feeble-minded. 

The recent advances in child study by which the stages of 
intellectual development during normal childhood are expressed 



190 

in terms of mental capability, determined by simple laboratory 
tests, have made it possible, by means of the same tests, to de- 
termine approximately the mental capacity of feeble-minded per- 
sons and thus express it in terms of mental age of normal children. 
I refer especially to the tests devised by Binet and Simon of Paris 
and first suggested to the American Association for the Study of 
the Feeble-minded by Dr. H. H. Goddard in June, 1908. 18 The 
Association in the following year, as the result of the report of a 
committee 19 on the subject, adopted a tentative classification 
based upon the use of these tests and suggested the term "moron" 
for the highest group. The whole subject was then left open for 
further investigation and discussion. 
The scheme was as follows : 

Classification of Feeble-Minded Tentatively Adopted by the Ameri- 
can Association for The Study of the Feeble-Minded. 



Descriptive terms. 


On scale 
of 10. 


Mental age as deter- 
mined by Binet tests. 


A. NORMAL: 


10 


13 


B. FEEBLE-MINDED: 

f High grade 


i) 
•1 


8-12 

3-7 
0-2 


Morons < Middle grade 

[ Low grade 

f High grade 

Imbeciles < Middle grade 

1 Low grade 


\ High grade 

Idiots \ Middle grade 

[ Low grade 





As the system of tests — these or their equivalents — is funda- 
mental to a practical application of the classification in detail, 
the first thing to scrutinize is their reliability. For our purposes 
there are two phases to this question of reliability; first, do they 
afford a correct means of determining the intellectual levels of 
normal children at all annual stages of growth from one to thirteen 



igi 

years; and second, is this age scale practicable for registering the 
mental capacities of the feeble-minded? 

As to the first point, it is a problem for the psychologists and 
the very extensive discussion which they have carried on during 
the last two years is witness that they are not neglecting their 
duty in this regard. The writer has followed enough of this 
discussion to note that while some of the details of the Binet- 
Simon tests are not considered perfectly adapted to the specific 
years for which they are intended, the most severe critics do not 
invalidate the system and at most only suggest certain improve- 
ments or modifications in the minor details. As to the practica- 
bility of the mental age scale for classifying feeble-minded, any 
readily applied scale of intelligence that could be used for all 
feeble-minded has been a long felt want and one that enables 
the examiner to compare feeble-minded with normal children, 
has a supreme value in that the mental status is at once compre- 
hended by every one, and a universal standard is thereby estab- 
lished. The writer has already referred to the expressed desire 
for something of this kind by several workers with this class. 

After an experience with the Binet-Simon tests of over one 
year, during which time they have been used in the careful men- 
tal examination of 1300 cases of all grades in the Minnesota 
School for Feeble-minded and Colony for Epileptics by a trained 
psychologist of sane judgment, judicial temperament and high 
professional standing, Dr. Fred Kuhlmann, the writer feels that 
Faribault can add its testimony to that of Vineland, where 
Goddard made the first institution survey — 400 cases — 20 , and 
Lincoln (Illinois) where Huey followed in testitig "most of the 
brightest children" 21 in an institution population of 1300, that this 
scheme of testing and classifying is a positive step forward in a 
rational classification of the feeble-minded, and its aid is a com- 
fort to the expert in making plain to the parents and friends what 
he recognizes without it. The grouping by mental ages, as shown 
by the above table, into the general triunal mental classification 
tends to clarify rather than to add confusion to the previously 
developed scheme, by standardizing the lines of separation, and, 
what is of most importance, affords a ready means of making a 



192 

quick diagnosis. From this sort of examination, the medical 
examination and the field survey of heredity and social environ- 
ment from which the child is received, one is able to secure the 
most complete data possible for determining the prognosis, and 
the intelligent planning of training and treatment. 

The writer has avoided so far the entire subject of pathology, 
not because of any disposition to ignore its value, but because 
it has seemed of most importance that the new mental classi- 
fication be first made clear. To it the other data can be affixed 
with a clearer idea of its relative value, both as to prognosis and 
the relative number of persons involved. 

In the matter of numbers, for instance, one would suppose from 
the prominence given by most writers to certain pathologic 
types, such as Cretins, Mongolians, Microcephalics and Hydro- 
cephalics, that they represented the great majority of feeble- 
minded children, while, as a matter of fact, they constitute but a 
very small percentage of them. In the institution of which the 
writer has charge, out of a population of about 1400 (including 
epileptics) there are only about 3 per cent, all told of the four 
types above enumerated. 

On the other hand, a knowledge of the type is exceedingly 
important. All the data concerning the pathology and the eti- 
ology is valuable, and the skill of the physician, psychologist and 
teacher must be joined in order to realize the best training results. 
For instance, as a rule, the congenital case is more susceptible of 
improvement under training than the inflammatory or sclerotic 
type of acquired defectiveness. The Mongolian's possibilities are 
quite well defined and his low life expectancy long recognized. 
Not only is the physiologic and pathologic data of great impor- 
tance, but it must be borne in mind that the danger that it will 
now be overlooked is imminent and must be guarded against. 
In the new classification, however, there is a place for all this data. 

Note the complete picture presented by the statement: "John is 
a fifteen-year old Mongolian imbecile — mental age 6"; or "Mary is 
a thirty -year old Microcephalic idiot — mental age 2 ;" or "William 
is a moron, a delinquent, eighteen years old— mental age 11 — has 
right hemiplegia from infancy." 



193 

The question may properly be asked, does this system of mental 
tests in itself determine the "defective delinquent," or, in other 
words, can all who pass the tests for normal intelligence be de- 
pended upon to make good citizens in good average environment? 22 

The reactions to the Binet tests or their equivalent are only 
significant of intellectual levels. 2S While their value is unquestioned 
in the field of juvenile delinquency, for quickly detecting the 
large number that present these low levels, the borderland cases 
present a more complicated problem that so far has not yielded 
to any laboratory analysis. Heredity, early environment and 
their known reaction to social conventions, as of old, are the best 
factors yet available from which the expert must judge of their 
future. 

REFERENCES. 

1 Barr, "Mental Defectives," Philadelphia, 1904, pp. 78-89, gives a full discussion of 
the older classifications. 

2 Proc. Assoc. Med. Offs. Am. Inst, for Id. and F. M. Pers, Vol. I, pp. 33-34. 

3 An Italian teacher, Montessori, has recently shown how Seguin's principles of sense 
training should be applied in the education of all children. 

4 Idiocy: And its Treatment. Teachers College Edition, Columbia University, N. Y., 
1907, p. 40. 

8 Tredgold. 6 La Page. 7 Shuttleworth and Potts. 

8 The Royal Commission in its own title. 9 Sherlock. 

10 Ireland, "Mental Affections of Children," p. 39. 

11 "Textbook of Psychiatry (McDonald translation)," N. Y., 1906, p. 430. 

12 "Mental Defectives," p. 90. 13 "Mental Deficiency," New York, 1908, p. 75. 

14 "Mental Affections of Childhood and Youth," Down, London, 1887, p. 120. 

15 "Mentally Deficient Children," Shuttleworth and Potts, p. 113. 

16 "a Manual, etc., of the Feeble-Minded, Imbecile, and Idiotic," Duncan and Millard, 
London, 1866, pp. 1, 3-14. 

17 Duncan and Millard made 8 rather arbitrary classes. 

18 Journal of Psycho- Asthenics, Vol. XIV, 1909, p. 48. 

19 The committee consisted of Fernald, Goddard, Wylie, Bullard and Murdock. For 
a fuller discussion of this subject, see Journal cf Psycho- Asthenics, Vol. XV, Nos. 1 and 2, 
1910. 

20 Reported, Journal of Psycho- Asthenics, Vol. XV, 1910, p. 17. 21 Ibid., p. 31. 

22 A very interesting study of laboratory methods as an auxiliary to sociologic data, 
with Juvenile Court cases, has been in progress for over two years in Chicago, under the 
direction of Dr. Wm. Healy, Director of the Psychopathic Institute. This is a work that 
gives promise of rich fruitage. 

23 For an analysis of results with Binet tests with high-grade morons, see Huey's "Back- 
ward and Feeble-minded Children," Baltimore, 1912. 



XX 
THE SUBNORMAL SCHOOL CHILD. 

By L. T. Royster, M.D., Norfolk, Va. 

Since the institution of. general and systematic medical inspection 
of school children, the conception of the delinquent child has 
undergone a radical change, and through no other single agency- 
will the conduct of large centers of primary education be more 
completely revolutionized. 

The laggard child has long been recognized as the most difficult 
problem of the graded school; the reason for this is that the true 
nature of retardation was not understood, for the time is not long 
past when all children who did not keep up with their studies 
were considered lazy or bad, hence frequent and severe punish- 
ments were the rule, without, however, the lessening of retardation. 
In sharp contrast to this view, is the modern scientific one which 
regards delinquent children as belonging to two general classes: 
the one mentally subnormal — usually from inheritance ; the other, 
and by far the larger, those whose mental faculties are impaired 
through physical defects. This problem has fortunately engaged 
the efforts of the most astute minds of all professions, for upon 
its solution depends the success of modern educational endeavor, 
the stability of our school system and to a large extent the in- 
tegrity of the nation. 

The laggard child may be described as one possessing an ap- 
parent inherent or constitutional inability to keep up with the 
course of study or grade which experience has shown to be the 
one best suited to the child of a given age. Manifestly a child's 
age in years is an exceedingly unscientific criterion by which his 
mental capabilities should be decided, for among children as 
among adults mentality varies greatly with individuals. It is 
not uncommon to find a child of six years capable of entering 
the first or perhaps the second grade of the public school course, 
or on the other hand one who even at eight or nine years of age 
with difficulty keeps up with the first-grade work, and yet it is 
determined by law in many states that a child of seven years must 



195 

be entered in the first grade. Thus it is seen that the very princi- 
ple on which entrance is based is conducive to retardation. 

I have long been of the opinion that in most of the public school 
curricula the error has been committed of fitting the course of 
study not to the capacity of the average pupil but rather to that 
of the bright one. Under such an arrangement it is evident that 
the dull pupil starts his school career with a serious handicap. 

A certain number of children are of course embarrassed by true, 
mental defects. These have been divided by investigators, 
notably Goddard, into three classes: The idiot for which, un- 
fortunately nothing can be done, except to place him in a sanitary 
and safe environment. The imbecile which has to be dealt with 
in institutions under competent and trained teachers and at- 
tendants. While in the third class belongs the "Moron" which 
is a child who is usually able to keep up with school work, and 
may be mentally indistinguishable from the normal child but in 
whom there is an inherited tendency to defection, usually moral, 
which may not develop, however, until the school age is past. 
I do not think that this class has been sufficiently studied to form 
a definite plan for their management. 

Irregular attendance at school is a not inconsiderable cause of 
retardation and elimination. This may be due to lack of interest 
on the part of parents; to sickness of the pupil himself or in the 
family, necessitating the child's remaining at home to care for 
other members of the family; long quarantine in case of contagious 
diseases (unfortunately an unavoidable cause) and among the 
poor, cases are common, where children are being frequently 
kept away from school, in order to be put to work. 

Among other causes which may be mentioned are the over- 
crowded curriculum, and of special potency the practice of adding 
too many pupils to the burden of the already overtaxed teacher, 
thus making it impossible for her to pay attention to the individual 
needs of the pupil. 

Viewed in the light of modern scientific studies, however, the 
majority of laggards are normal children mentally, but em- 
barrassed by physical defects, which in turn impair the mental 
faculties to an extent which is sufficient to place them in the sub- 



196 

normal class. Ever since the first foundation of society, the 
criminal has been recognized as belonging to a distinct class of 
humanity; an individual whose instincts were diverted by nature 
from their normal channels; but it remained for Lombroso and 
his followers to study this class along scientific lines with the 
physical as a basis which in many instances was of more impor- 
tance than heredity. Similarly ever since we have had schools 
the laggard has been recognized as so distinct a type that in none 
of the older pictures of the school-room was there ever absent 
the dunce-capped boy on the stool in the corner and the begrizzled 
master standing with rod in hand ready to thrash the lesson into 
him. 

Fortunately for these children the twentieth century scientific 
principle has come to their aid through the efforts of such men as 
Drs. Witmer, Gulick, Ayers and others, who have conclusively 
proven that by correcting existing physical defects the great 
majority of laggard children could be speedily raised from their 
position at or near the foot of a repeated grade to the point of 
completing the course slightly if any behind the average pupil. 

From such investigation and the unquestionable results of the 
same, it will be readily seen that the greater number of these 
unfortunate laggards are the victims of physical rather then men- 
tal defects, and that in their impaired physical condition we are 
presented with the most far-reaching cause of repetition in school 
work. 

The effects of retardation on school, child and community, are 
so numerous, and far-reaching that a comprehensive consideration 
of them would far exceed the limits of this paper. I shall merely 
suggest a few, hoping thereby to stimulate others to study more 
exhaustively these complex situations. 

The detrimental influence of the presence of one or more pupils 
in a grade, who are unable to keep abreast of the course of study, 
is so obvious that it is not necessary for me to dwell on it. The 
whole class is reflexly retarded for the benefit of the few and the 
progress of a room is generally unsatisfactory. 

Further, this condition promotes laziness and inattention on 
the part of the bright pupil (only too often themselves a menace 



197 

to the room because of their brightness) on account of the ease 
with which they accomplish their daily task. Also the average 
pupils lack sufficient incentive of competition to make them above 
the average which many of them would no doubt become through 
greater mental activity. Nor does the baneful influence end with 
the pupils, for it cannot fail to react on the teacher in ultimate 
discouragement and impaired usefulness. 

But what of the effect on the child itself and the community 
at large? The child is first discouraged and then attention ceases 
to be fixed because of its inability to grasp the lesson; finally 
completely disheartened it becomes a drone in the school, retarding 
the progress of the other pupils, and unable to occupy its time 
with the routine work of the school, gives vent to the accumulated 
animal spirits in mischievous pranks which being oft repeated 
ultimately lower the moral tone of the whole school. In addition 
to vicious tendencies thus formed, these children who have not 
kept up with their work and having frequently repeated a grade, 
soon leave school before the completion of the course, and having 
failed to learn concentration of energy and self-control, are not 
only unfitted for the usual vocations, but are even a menace to 
society; running the gamut of youthful indiscretion, petty offenses 
against the law, and only too often crimes of the worst sort; 
subsisting on dishonesty and successfully evading arrest, or on 
the other hand becoming too bold and less vigilant, are appre- 
hended and become burdens on the Commonwealth as term 
prisoners in the state penitentiary. 

It has been estimated that repeaters in our schools cost — be- 
cause of repetition — the people of the United States in one year 
$27,000,000.00. This is merely while they are attending school. 
It is of course impossible to compute the cost of their maintenance 
in after-life, as non-producers and prisoners — hence parasites on 
the community in which they live. Therefore from an economic 
standpoint alone this class is deserving of our most careful in- 
vestigation. 

Finally, let us see briefly what can be done for this problematical 
child ; what can be done to help him keep up with the curriculum, 
to bettef fit him for life's battles, to make him a useful and wealth- 



198 

producing citizen and to lead him into the way of right living and 
away from vicious habits and his consequent appearance at the 
juvenile court, the higher court or only too frequently the prison 
cell. 

The first and most important remedial measure is efficient and 
adequate medical examination of all school children. Such 
examination should have for its object the correction of defects 
of vision, by properly fitting glasses, thus relieving eye strain and 
securing a correct perception of the written or printed word or 
phrase, without which the conception is faulty, and its repro- 
duction correspondingly inaccurate. Likewise impaired hearing 
which bears the analogous relation to the spoken language. 

The removal of adenoids and tonsils when unusually enlarged 
or diseased. Careful attention to the teeth, bodily cleanliness, 
posture at desk, school lighting, and the general hygiene of the 
school building. All of these should be attended to most care- 
fully during the formative years of the child's school life, for 
impressions gained at this time are of vital importance, and a 
faulty primary education can never be corrected, even by the 
most elaborate higher learning. 

No examination of school children is complete without the 
application of the Binet test for mentality, for only in this way 
can we fit the grade to the child rather than the child to the grade 
as is usually done. The school nurse is an indispensable adjunct 
to medical inspections not only in assisting in the examinations 
but in carrying the gospel of right living into the home. And 
I am convinced that so far as is possible the nurse should per- 
sonally interview the parents, when medical attention is needed, 
rather than the promiscuous use of the printed notice, which is 
often misunderstood by the ignorant, causing frequent and 
unnecessary absences. 

The question of individual temperament should be given careful 
attention in order to determine the natural inclinations of the 
child. This is perhaps the point most frequently neglected by 
all teachers. 

The modern student of child delinquents, however, does not 
confine himself to the study of sight and hearing but makes further 



199 

observations along broad and concise lines, including such things 
as the sense of touch, motor control, coordination and the state 
of nutrition and inquiries into the amount of sleep which the child 
secures, the amount and character of the exercise taken, his powers 
of observation and by no means the least of all, his home environ- 
ment, which is one of the most important factors in the formation 
of character. Such studies as these and the handling of children 
along the lines indicated has produced apparently miraculous 
results, developing average and even bright pupils from those 
previously considered by their teachers as hopeless laggards. 
In large centers of population an ungraded school should be 
maintained where those of unusually lowered capacity may be 
placed, where the child should be taught and handled according 
to its individual needs, looked after by the medical examiner 
separately and minutely and developed along lines in which it is 
especially deficient. Where the separate school cannot be main- 
tained each building might have a room or there might be a room 
for each two or three buildings in which one teacher might well 
handle five or six such children and bring them to a better under- 
standing of the subject matter in hand. One fact which should 
be borne in mind in the teaching of sub-normal children is that 
five or six children should always be the limit for each teacher. 
I am greatly gratified by one important observation which this 
study has developed and that is the important part played by 
manual training in the handling of these children, for it not only 
gives them something to do which is at once instructive and 
interesting but it teaches observation, care, precision, accuracy, 
coordination, motor control and economy. Adequate attention 
to defectiveness cannot be paid without the assistance of district 
nurses who will follow up the case at home and instruct the par- 
ents as to the necessity of having children properly cared for. 

The open air school is a promising aid in the furtherance of 
this cause and I hope to see the time when every school which is 
erected will have a roof garden or other arrangement for this 
purpose, while semi-annual promotions are rapidly coming to 
be the rule. Carefully kept records of the physical condition of 



200 

pupils, the amount of improvement, after-treatment, their prog- 
ress in their studies, etc., are absolutely essential to the efficiency 
of the undertaking in hand. 

It was Gladstone who said that on the health of the people 
depended the strength of a nation. Our nation is growing from 
within, countless hordes of immigrants are making daily assaults 
on our shores, in a friendly warfare, a struggle for that liberty 
which only America has to offer. In the education of all the people 
not alone in book knowledge but also in that knowledge which 
will teach them how to live and thus make us the great and virile 
nation which God intended that we should be, lies the safety of 
the nation in the future. Make the people healthy mentally, 
morally and physically: the nation will be strong. The medical 
school inspector and especially the visiting nurse who will carry 
the principles of right living into the home itself can accomplish 
this. 



XXI. 

THE TEACHING OF SOCIAL ETHICS, AND ITS RELATION 
TO THE CONSERVATION OF THE CHILD. 

By Winfield S. Hall, Ph.D., M.D., Professor of Physiology, Northwestern University 
Medical School, Chicago. 

The term Social Ethics is a comparatively new one. Its sig- 
nificance is so evident on its face that it hardly needs definition. 
One assumes that it refers to the right and wrong of social inter- 
course and that is just what it signifies. While sociology is the 
science of human society and ethics the science of the right and 
wrong of human activities, social ethics may be defined as the 
ground common to ethics and sociology. In short, it deals with 
the right and wrong of social intercourse in human society. 

In order systematically to present this matter, it may be stated 
that Social Ethics concerns three planes of human activities and 
relationships: First, the personal plane, which deals with and 
sets forth personal conditions, personal attitudes and personal 
habits, which form the basis of and give the trend to the social 
relations. While the activities in this plane might seem not to be 
social, as a matter of fact they are basic in their relation to the 
social and must be considered in this connection. Secondly, 
the family plane, which deals with and sets forth family relation- 
ships in so far as they concern ethics and society. Third, the 
social plane which deals with the right and wrong of social re- 
lationships in human society outside the family. 

Social and domestic happiness and well being are so indissolu- 
bly linked with ethical standards, ideals and practices that it 
becomes absolutely essential that all those constructive forces 
of society pledged to conserve and protect society be marshaled 
against social wrongs and reinforce social good. 

Expressions which have been frequently heard in the last dec- 
ade as "the social evil," the "venereal peril," etc., indicate the 
preponderant social wrong from which society suffers and the 
predominant retribution which nature seems to mete out against 
this wrong. As a matter of fact, a very large part of ethical wrong 



202 

living has to do with the sex life, and is usually manifested in all 
three planes mentioned above, namely, personal, domestic 
and social. While it is true that the venereal peril menaces the 
innocent, as well as the vicious, it is also true that if all people 
would live absolutely clean and correct sex lives for two genera- 
tions, venereal disease would become as rare as smallpox or 
cholera, while now it probably affects in smaller or greater de- 
gree at least fifty per cent, of the whole population. These mil- 
lions suffer either innocently or otherwise, for the sins of others or 
for their own shortcomings, the saddest of all being the results 
of inherited taint. 

If we may rely upon statistics, the social evil is getting worse 
rather than better. Even the optimist must admit this, and while 
he sees commercial, industrial and political conditions improv- 
ing step by step, he is forced to admit that social conditions are 
getting worse. We do not have to look far for the cause. A 
glance at the last two government census reports shows that our 
population is setting toward the great urban manufacturing 
centers, large regions of our rural districts barely holding their 
own in population during the last generation, some actually de- 
creasing. If this centering of the people in great cities and rapidly 
growing towns could have been controlled, the ills and wrongs 
might have been largely avoided, but they were not controlled, 
in fact we are only now discovering the unfortunate tendencies 
which have been at work. People have huddled together in 
such close proximity that vegetation is huddled out and breath- 
ing spaces contracted. Furthermore, in large districts of our 
larger cities, the housing of the people is shockingly Bohemian. 
Where a whole family — parents, grown children, adolescents 
and younger children — is housed in one room, which one room 
must serve as kitchen, laundry, dining room, parlor and sleeping 
room, it goes without saying that young people growing up un- 
der such conditions lose or rather never experience the senti- 
ments and feelings associated with modesty and refinement. 

Young people in our great industrial and commercial centers 
are crowded together in the department stores, shops and fac- 
tories under conditions that are not only unsanitary and unhy- 



203 

gienic in many cases, but at the same time may be unwholesome 
from a social standpoint. After their eight- or nine-hour day 
under these undesirable conditions we can easily understand 
why the young people would wish to seek entertainment and 
recreation from their mechanical and unstimulating shop work 
at the same time that they seek escape from the wretched home 
conditions. We are therefore not surprised to see them flock- 
ing to the cheap vaudeville and moving picture shows, and to 
the public dance halls, where they are likely to be subjected to 
destructive suggestion that will tend to rob them of what little 
of right standards remain after the effects of their home and 
shop influences have done their work. Summarizing then, we 
find that the destructive influences of urban conditions in the 
housing of the people, in the employment of the people, and in 
their recreative activities are tending more and more to lower 
social standards. If conditions are not changed social dissolu- 
tion will surely follow in a few generations. 

These unfortunate conditions mentioned above menace the 
home. Now the home is the foundation of human society. 
There could be no church; there could be no State; there could 
be no educational system without the home. If the home — if 
the foundation of human society — crumbles, the whole super- 
structure would come down in ruin, and we would have social 
anarchy. 

But this is not to happen. There is a general awakening. 
We have been analyzing conditions, diagnosing the social dis- 
ease. We have determined its etiology. Having found its 
cause, the rational treatment has already been begun. 

A study of the social conditions makes it evident that a vast 
preponderance of social ills are visited upon the people because 
of ignorance. Little children fall into error because they have not 
had the benefit of wise counsel and guidance. Young people 
make blunders because they are ignorant of personal physiology 
and hygiene. Older people through ignorance or indifference 
need education and an awakening. The writer believes that the 
only rational cure for present social conditions is to be found 
in education. Wise laws justly and firmly administered will 



204 

help. Public institutions for the reclaiming of the fallen will 
also help. These two measures last named alleviate in a super- 
ficial way only. What we must seek to accomplish is to remove 
the cause so that these ills will not exist and therefore not need 
alleviation. In the social evil as well as in the drink evil, it is 
necessary that the education — the rational prophylaxis of the 
evil — be begun in youth. It is very much easier to keep a young 
life straight than it is to make it straight once it has become 
bent and distorted. Let us then emphasize again the para- 
mount importance of education as the great prophylactic agent 
to protect society from the ills that follow wrong living. 

Inasmuch as the difficulties to which we have referred begin 
in childhood and youth through innocence and ignorance, it 
must be evident that the education must begin in youth. Those 
who have given this problem extended study and thought all 
agree that education in social ethics is a home problem. Parents 
must teach their children the great truths of life. Coming from 
parent to child this teaching will be certain to have its two great 
essentials, namely, sincerity and sympathy. However, we find 
that a very small proportion of the present generation of parents 
possess either the requisite information or the necessary inclina- 
tion to give this instruction. 

There must be a transitional period, during which educators, 
social workers and all the constructive forces of society work 
together to produce a generation of parents who will possess 
both the information and the inclination. That means that we 
must go into the schools and teach the great truths of life to the 
children and youth. In this great work for society, let us never 
lose sight of the fact that we are doing this work in our relation 
of vicarious parenthood. We must school ourselves to feel 
toward these young people as a parent feels toward his child. 
The instruction must be given in all seriousness, candor and 
simplicity. It must be put on the plane of the ideal. There 
should be an attitude of sympathy toward the pupil. Those 
who have not had experience in this teaching can hardly con- 
ceive how beautifully the young people respond in their intense 



205 

attention, and in the seriousness with which they receive the in- 
struction. 

The education of the youth in this transitional period should 
begin in colleges and universities. It may be said in passing 
that a considerable number of our institutions of higher learning 
have already made a good start in this teaching. We may look 
forward with assurance to a time in the near future when all 
these institutions will recognize their obligation in this direction 
and will have this instruction given systematically. 

Instruction in social ethics and sexual hygiene must also be 
introduced into the high schools. Most high school pupils are 
in the earlier period of adolescence. The need for instruction 
is at no period of life greater than at the threshold of adolescence. 
The response of the pupil is at no period of life more ready or 
wholesome. It is, therefore, a matter of the greatest importance 
that instruction in social ethics and sexual hygiene be introduced 
into all the high schools of the land at the earliest possible day. 

Pupils in the grammar schools need certain facts brought to 
their attention, and this need is hardly less imperative than is 
the need in the high school. The girls of the seventh and eighth 
grade are as a rule coming into adolescence. Probably a large 
majority of eighth grade girls in general are in their first or sec- 
ond year of puberty. Their mind is filled with questions about 
life and they instinctively show a sort of hypersensitiveness on 
sex matters. Their mothers as a rule have not instructed them. 
The schools must do it. 

The problem of the grammar school boy, while less a sex 
problem than one of inherent barbaric vulgarity, is still one 
that requires great tact, patience and skill on the part of 
the teachers. The seventh and eighth grade boy is still in his 
preadolescent period, still in his period of barbarism. He has 
not felt the primordial urge in his red blood, but he does 
show the barbaric tendency to crudeness, rudeness and vulgarity. 
While we are not going to lose our patience with this boy, nor are 
we going to become discouraged about him, we are going to ex- 
tend to him from our elevated position of twentieth century 
chivalry a sympathetic helping hand that will guide him quickly 



206 

through his storm and stress period and help him early to step 
up out of barbarism into his period of dawning chivalry. 

This teaching in the grammar school requires incomparably 
greater tact and pedagogic skill than the teaching in colleges. 
It must be done by trained teachers; professional people either 
physicians or social workers called in from the outside cannot 
do this work for the simple reason that the number of physicians 
and social workers who possess the pedagogic skill and knowledge 
of, and sympathy with, child life is wholly inadequate to meet the 
requirement even if they were to devote their whole time and 
energy to it. Besides that the psychic effect on the pupils of 
calling in somebody from the outside is unwholesome and stu- 
diously to be avoided. It enshrouds the whole matter in a haze 
of mysticism and excites the curiosity and a tendency to talk 
among themselves with great danger of unwholesome results. 
This teaching of the great truths of life concerning reproduction 
and sex must be done by the teachers of the grammar school, 
but the teachers of the grammar school are not prepared either 
in their own mental attitude, the information they possess, or in 
their pedagogic training. The whole field of sex is to a vast 
majority of teachers a terra incognita. For a period of four or 
five years before we require sex instruction in the grammar 
schools the subject of social ethics, social hygiene and sexual 
hygiene should be taught in the normal schools.. 

The normal school course in social ethics should acccomplish 
three very clearly defined objects: First, to give the pupil 
teacher a wholesome view-point concerning Social Ethics in all 
its bearings, displacing false modesty with real modesty and 
leading the student from the dimly lighted valley of prudish 
ignorance to the high sun-bathed mountain tops of idealistic 
virtue. Such a change of mental attitude is wholly and solely 
a matter of education and is the first thing to accomplish for the 
pupil teacher. Second, to give the pupil teacher adequate in- 
formation concerning the biology of reproduction, the physiology 
and hygiene of the sex apparatus and sex life, also the sociological 
and ethical principles involved in sex hygiene and social ethics. 
Third, to train the pupil teacher in the principles of pedagogy of 



207 

this particular subject. It may be stated in passing that the 
teaching of no subject requires greater pedagogic skill and tact 
than this one. In the presentation of no subject does the teacher 
require a greater knowledge and insight into the psychology of 
youth than is required in the teaching of sex hygiene. 

After all of the normal schools of a State have had a course 
in sex hygiene and social ethics presented to every student in 
the school for a period of four or five years it may be wise and the 
time may be ripe for requiring this teaching in the grammar 
school, because by that time there will be many hundreds of 
teachers in the State who will have been trained for this teaching 
and the probabilities are strong that almost every village and 
city school will have on its corps of teachers from one to a half 
dozen who will have had the benefit of this instruction in the 
normal school and who will be prepared to give this instruction 
in an acceptable manner. 

Answering the question, when and how shall this instruction 
be given in the ideal case, let us repeat what was stated above 
that this is a home problem. Fortunately, Nature points the 
way with a great shining index. Nature has implanted in the 
heart of every child the instinct of asking questions. The mother 
and teacher have only to answer these questions when they are 
asked, answering briefly and simply and always in a spirit of 
sympathy and love, to rest assured that they are following not 
only the plan of Nature but also the plan of the God of Nature. 

The first question asked by the child is almost certain to con- 
cern his origin. The little five-year-old girl creeps into mamma's 
lap at eventide and nestles her head on mamma's breast and asks, 
" Mamma, where did you get me?" Then she waits for mamma's 
answer. No real mother, under such circumstances, could bring 
herself to the point of telling the stork story to her child. Such a 
response to such a question would be unworthy the twentieth 
century mother. You may be interested to know what one 
twentieth century mother told her child in response to a similar 
question. Her little six-year-old boy was brought to his mamma's 
bedside and introduced to his two-day-old baby sister for whom 
he had watched and prayed for several months. He was very 



208 

happy, God had answered his prayer ; presently he asked : " Mamma 
where did the baby come from? " This was the mother's answer: 
' ' Baby sister came out of mamma's body. She was formed within 
mamma 's body , she was formed from materials drawn out cf mamma's 
blood, and that is the reason why mamma's cheek is so pale and 
mamma's hand so thin and white." The little boy's eyes opened 
wide with wonder. This story was to him incomparably more 
wonderful than the stork story would have been. He looked 
thoughtfully from mamma's pale face to the little baby sister, 
back and forth several times. Then he asked this question: 
"Mamma, was I formed within your body too?" The mother 
answered: "Yes, my boy, you were. You were formed within 
mamma's body, you were formed out of mamma's blood, and that 
is the reason why mamma loves her boy so, because she gave her 
own life's blood for him." The little boy's eyes now took on a 
far-away look and he seemed to be trying to grasp the great thought 
of mother sacrifice. He evidently did catch at least a glimmer 
of the great truth, because after a few moments his eyes welled 
full of tears and turning to his mamma he threw his arms about 
her neck and said : ' ' Oh mamma, mamma, I never loved you so much 
before," and the little boy meant it too, because from that day 
forth for many weeks he seemed to think of little else during his 
waking hours than what he could do to help the mother who had 
been so ready to sacrifice for him. This happened eleven years 
ago. The boy of six has grown into the young man of seventeen, 
stalwart, broad-shouldered, deep-chested, hard-muscled, clear 
of eye, clean of life, and chivalrous. He must be the pride of 
his father's heart and the joy of his mother's heart. He is a 
neighbor of mine, and I have watched his development with 
great satisfaction. His attitude towards all womankind seems 
to be inspired by instincts of chivalry and honor. That this at- 
titude has been developed by the teaching which his mother has 
given him from boyhood up, supplemented perhaps by some in- 
struction and example on the part of his father, no one can 
doubt. Can there be any question that when the time shall 
come that all boys and young men will have been led into chival- 
rous young manhood in a similar way and when all girls and 



209 

young women shall have received from their parents a training 
which will give them a reciprocal attitude towards mankind, 
then the social problem will have been solved? Its solution is a 
matter of education, pure and simple, and this education must 
begin in early childhood. 

The next question which the child asks as a rule concerns the 
physical differences between the sexes. Your little six- or seven- 
year-old girl may come with this question : as to how the mother 
knows whether her new-born baby is a boy or a girl. This is a 
fair question and must be answered, otherwise a suspicion of 
mystery is at once aroused and a gnawing curiosity is developed. 
The wise mothers in all generations have adopted a very simple 
method of forestalling this question and presenting in the family 
conditions which answer the question in the most natural and 
simple way. I refer to the custom adopted by the wise mothers 
in all generations of having the little children of the family meet 
in the nursery at bedtime at least one evening in the week in what 
some mothers call an "undress parade." Other mothers call 
it a "bath night frolic." The little boys and girls of the family 
ranging in age between two and seven or eight years, enter into 
these frolics with the keenest and most unalloyed pleasure. 
Never so free of movement, never so happy, and it may be said 
in passing, never more modest, than when freed from the hamper- 
ing habiliments with which civilization has clothed us. As re- 
cently as four thousand years ago our ancestors were practically 
nude savages living in the forests of Southeastern Europe and 
Western Asia. They were children of Nature and like these 
babies of our twentieth century Aryans so far from being immodest 
in their nudeness possess what the sociologist recognizes as abso- 
lute modesty, that is, modesty so perfect that in the nude they 
are unconscious of their nakedness. 

Incidentally, little six-year-old Margaret is almost certain to 
note a difference between herself and little Mary, on the one 
hand, and Jimmie on the other, and will remark in her childlike in- 
nocence to her mamma : "Little Jimmie isn't made the same as Mary 
and I, is he mamma?' ' And the mamma will answer in a perfectly 
matter-of-fact tone: "No, little Jimmie is made like all boys and 



2IO 

men, while you and Mary are made like all girls and women." 
This answers the question for all time so far as Margaret is con- 
cerned. In their turn each of the other children will ask simi- 
lar questions or make similar remarks to be answered in the 
same matter-of-fact way, and to grow up without morbid curiosity 
regarding structural differences between the sexes. If some of 
you are worrying about Margaret 's modesty let the writer assure 
you from the uniform experience of hundreds of mothers with 
whom he has conferred that when Margaret reaches the age when 
impulses and instincts of modesty usually appear in a girl, they 
will dawn in the soul of Margaret as naturally as the rose in the 
garden blooms in June. If a girl grows up in the atmosphere 
of modesty and consideration, the atmosphere being determined 
by the mental attitude and the habits of the older people of the 
family, rest assured that when the child approaches puberty 
the instincts and feelings of modesty come into their experience 
as a natural and inherent heritage of our race. 

When the children approach puberty, there should be a parting 
of the ways for the girls and the boys of the family, the girls 
coming into a closer comradeship with the mother, while the boys 
are led and inspired by the father. It is the inherent right 
of every girl to be led into beautiful exultant womanhood by a 
loving mother, and it is equally the inherent right of the boy to be 
led into clean, aggressive, triumphant manhood by a fond father. 

As the mother sees her daughter growing rapidly in stature 
at the age of twelve to fourteen, and recognizes that this sud- 
den growth in stature heralds the approach of womanhood, the 
mother seeks an opportunity to instruct her daughter in the 
ideals of womanhood, giving her the facts that she needs to know 
to guide her through the many problems, personal and social, 
that confront the adolescent. There are three important lessons 
that the wise mother teaches her daughter. 

The first lesson for the girl to learn is the "Secret of woman- 
hood." The mother may picture the typical twelve-year-old 
girl in all her lean and lank, awkward, and gawky, clumsiness, 
self-conscious, ungainly and unprepossessing in the highest degree. 
This preadolescent girl is in her "ugly duckling" stage of de- 



211 



velopment. Now let the mother picture what the girl is to be 
in four or five short years. Graceful in figure, graceful in every 
movement of her body, possessed of poise and repose, her rosy 
cheeks glowing with the red blood of good health, her lustrous 
eyes luminous with the light of radiant young womanhood. 
Then the mother reveals to the daughter the secret of this re- 
markable change and tells her how when the little girl is about 
thirteen years of age her ovaries begin to prepare a wonderful 
substance, that was absorbed into the blood and through the blood 
distributed all over the body where tissues were growing and 
changing, and that this wonderful substance — this magical 
stimulus — formed in the body for that purpose causes this re- 
markable transformation in the little girl's body and no less re- 
markable a change in her soul, possessed first of purity, 
that matchless quality that runs like a golden thread through 
the whole fabric of her life, second, of altruism or unselfishness, 
that second great quality of the soul of woman, also of other 
hardly less beautiful qualities that make her soul so beautiful 
that when once it is really seen one is after that hardly conscious 
of her body however perfect that may be. 

The mother explains to her daughter that this great change that is 
the first step of developing womanhood is due to a substance formed 
in her ovaries — formed in her sex apparatus. When the girl knows 
this great truth, she naturally from that day forth looks upon 
her sex apparatus as sacred to her womanhood and a few words 
of counsel from the mother will guard the daughter against 
permitting or indulging anything that will irritate or excite this 
part of her body, being assured that such irritation and excita- 
tion will disturb the great work which in the plan of the Creator 
her sex apparatus must do for her womanhood. 

The second lesson which a mother teaches her daughter is a 
simple, clear explanation of the monthly period which is soon to 
be a part of the daughter's experience. She forestalls fears and 
forebodings by explaining to the daughter that this experience 
which may be difficult at first to adjust herself to, is in the plan 
of the Creator her preparation for future motherhood. As this 
healthy-minded, perfectly normal, twentieth century girl is look- 



212 

ing forward to future motherhood, as a natural and much- to-be- 
desired experience, her mother's explanation is accepted in the 
right spirit and the girl looks forward with confidence and serenity 
toward her approaching estate of womanhood. When it comes, 
all its experiences are accepted as a matter of course and in a 
spirit of assurance. 

The third lesson which the mother teaches her daughter con- 
cerns her relation to her young gentlemen friends. Even though a 
girl may not formally enter society until she graduates from high 
school, she is in reality in society as soon as she enters high school. 
Adolescent high school young people are experiencing the social 
impulse and yielding to the social instinct. The relations of young 
people in the high school are in all seriousness social relationships 
and should be so viewed by all who have any relationship to 
secondary education. So the girl's mother prepares her early 
for this new relationship by explaining to her the ideal social 
relations between young women and young men of her cir- 
cle. The information that the mother has given her daughter 
in the, first two lessons makes it very evident to this budding 
woman that her person being sacred to her womanhood she should 
not permit any familiarities on the part of her young men friends. 
Parents and teachers, perhaps through the organized agency of a 
Parent- Teachers Association, will cordially co-operate in the 
bringing about of ideal social conditions in the high school. 
All gatherings, whether formal or informal, of high school young 
people will be chaperoned. This chaperonage should be as wise 
and tactful as it is constant. 

It is the inherent right of every boy, particularly between the 
ages of ten and fifteen, to have the guidance and the inspiration 
of his father. During this stage of a boy's development, the pre- 
adolescent stage, the boy is living over again in his psychic and 
social development that period of his race when his ancestors 
were in a barbaric stage of civilization. So the boy of ten to 
fourteen is in a way a barbarian. He may be cruel and vulgar, 
he is sure to be blundering and blustering, especially if he is a 
really, healthy normal boy. His mother and his woman teacher 
are taxed to the limit of patience with this young barbarian. 



213 

It is the time of his life when he needs the firm, kind hand, per- 
haps the strong arm of a man, to guide, inspire and control him. 
Boys of this age have the benefit, not only of a father's influence, 
but also of the influence of a man teacher, perhaps in addition 
to this the help of boy leaders in Y. M. C. A. or boy scout work. 
The boy is in his age of hero worship. The robust, the sturdy, 
the daring, the belligerent experience and exploits of men appeal 
to him. He quickly scans the gapes of history and picks out 
as his heroes David the Bear Killer, the Lion Killer, the Giant 
Killer, the leader of his nation's armies; Alexander the Great 
(Military Master of the World) ; Caesar, Leader of the 
Legions of Rome; Napoleon, dauntless dictator of the destinies 
of Europe; Washington, and others of our own National heroes. 
All of these heroes are fighters. War and the chase are in his 
blood. Those qualities of his father that appeal to him and lead 
him to put his father's name on his list of heroes, are not the 
qualities that appealed and still appeal to his mother to inspire 
her love and confidence, but they are the qualities of barbaric 
heroism. Those qualities of physical agility and endurance 
which helped his father to win athletic victories and break ath- 
letic records. They are the qualities that were developed and 
fostered in war and the chase. So the wise father, the twentieth 
century father, becomes a chum of his boy not later than his 
tenth year. He cultivates a real live interest in his boy's activi- 
ties and aspirations. He attends the track meet between his 
boy's school and the neighboring schools, acting as referee, um- 
pire or judge on the occasion. He takes half holidays during 
the summer vacations to join the boys in their ball game in a 
vacant cow pasture. He goes on short camping trips with his 
boy and on many a long tramp. In these ways he and his boy 
become chums, comrades in war and the chase. It makes the 
boy more mature and thoughtful, more self-reliant and confi- 
dent, while it rejuvenates and rests the father. Once the boy's 
confidence and love are inspired, the father sets about syste- 
matically to give him three great lessons in life, beginning his 
instructions where the mother left off. 

The first lesson which the father teaches his son is the lesson 



214 

of manhood and the secret of virility. He describes what it 
means for a boy to grow into a man and how after a brief period 
of lank, awkward, self-conscious clumsiness the boy develops 
masses of muscles on shoulders and chest, upper arms, forearms, 
back, hips, thighs, legs. When these muscles come under the 
control of his will as they should in his early teens he will have re- 
ceived from mother Nature the three B's of young manhood, 
namely, Bone, Brawn, Brain, so that at eighteen years of age the 
young man should be able to stand out before the world broad- 
shouldered, deep-chested, erect, supple, hard-muscled, fiery- 
eyed and resourceful, full of initiative and will power, ready to 
get into the world's work. Then the father tells him the secret 
of manhood and explains about the internal secretion that is 
prepared in the boy's testicles from his fifteenth year on and that 
this internal secretion absorbed in the blood and distributed 
throughout the body causes the development in the youth of 
all these qualities distinctive of virile manhood, deprived of these 
sex glands the boy would develop first, into a sissy and finally 
at twenty-five he would be a slope-shouldered, narrow-chested, 
flabby-muscled, beardless, squeaky-voiced mollycoddle, abso- 
lutely lacking in every instinct and attribute of manhood. When 
the boy hears this from his father he readily understands that 
his sex apparatus is sacred to his manhood and that he should 
never do anything to irritate or excite it for fear of disturbing 
Nature's plan for his development of all these matchless quali- 
ties of manhood. 

The second lesson which the father teaches his son is a simple, 
clear explanation of the nocturnal emissions or so-called "wet 
dreams." The father explains that every two to four weeks a 
liquid will flow from the boy's sex apparatus. This usually hap- 
pens when the boy is sound asleep. He suddenly awakens to 
find that what has happened is a very simple little physiological 
phenomena that is perfectly natural and simply means a re- 
lieving of local tension. All the boy needs to do about it is to 
forget it and pay no attention to it. However, it is very impor- 
tant that the boy understands about this experience, which will 
be periodical and may last for many years, otherwise he is likely 



215 

to worry about it, assuming that he is subject to a sexual weak- 
ness. Not only do young men frequently misunderstand this 
matter, but it is frequently misunderstood and misinterpreted 
by others. It is just as important for the young man's mother 
to understand this phenomenon in the sex life of her son as it 
is for the father to understand about the monthly period of his 
daughter. 

The third lesson which the father teaches his son concerns the 
social relationships with his girl friends. Helped by a little wise 
guidance and instruction from his parents the boy readily adapts 
himself to the impulses of chivalry which are stirring in his 
breast. While these impulses are of inestimable value in de- 
veloping the highest social qualities they need guidance. It is 
the unguided and unschooled social instinct that leads the 
young man to make an advance toward familiarity in his rela- 
tion with his girl friends. The impulse to protection when un- 
guided would prompt him to put his arm about his girl friend. 
The same impulse under guidance inspires in him the attitude 
and the daring of the chivalrous twentieth century knight doing 
homage to a lady of the court ready to endanger his life to pro- 
tect her and ready to fight to the death in defense of her name 
and honor. 

Where parents and teachers co-operate to teach the youth 
these great lessons of life we insure the conservation, in the child 
of the race, of those qualities that make for the fullest manhood 
and womanhood. Physical health is preserved and physical 
stamina developed. Psychical poise is maintained and the high- 
est ambitions inspired. The youth of the race is conserved 
through this early and tactful teaching of the great laws of life. 



XXII. 

THE COLORADO METHOD FOR THE EXAMINATION AND 
CARE OF PUBLIC SCHOOL CHILDREN. 

By Mary Elizabeth Bates, M.D., Denver, President Humane Education Society. 

The following is the Colorado law: 

AN ACT PROVIDING FOR THE EXAMINATION AND CARE OF CHIL- 
DREN IN THE PUBLIC SCHOOLS, AND MAKING AN AP- 
PROPRIATION IN CONNECTION THEREWITH. 

Be it Enacted by the General Assembly of the State of Colorado: 

Section i. The State Superintendent of Public Instruction shall prepare 
or cause to be prepared suitable test cards, blanks, record books, and other 
needful appliances and supplies to be used in testing the sight, hearing and 
breathing of pupils in the public schools, and the necessary instructions for 
their use; and shall furnish the same free of expense to every public school 
in the State. The teacher or principal in every public school, or where there 
is no principal, the county superintendent, shall, during the first month of 
each school year, test the sight, hearing and breathing of all pupils under his 
charge, such examination to be made by observation without using drugs or 
instruments, and without coming in contact with said child; and keep a record 
of such examinations according to the instructions furnished ' and make a 
written report of such examinations to the State Superintendent of Public 
Instruction as he may require. 1 

Sec. 2. Every teacher in the public schools shall report the mental, moral 
and physical defectiveness of any child under his supervision, as soon as such 
defectiveness is apparent, to the principal or, where there is no principal, 
to the county superintendent. Such principal or county superintendent 
shall promptly notify the parents or guardian of each child found to be defec- 
tive, of the child's defectiveness, and shall recommend to such parents or 
guardian that such child be thoroughly examined as soon as possible by a 
competent physician or surgeon with special reference to the eyes, ears, nose, 
throat, teeth and spine. 

If the parents or guardian of such child shall fail, neglect or refuse to have 
such examination made and treatment begun within a reasonable time after 
such notice has been given, the said principal or superintendent shall notify the 
State Bureau of Child and Animal Protection of the facts; Providing, however, 
that whenever it shall be made to appear to the said principal or superintendent, 
upon the written statement of the parent or guardian of said child, iliai such parent 
or guardian has not the necessary funds wherewith to pay the expenses of such 
examination and treatment, the said principal or superintendent shall cause 

1 Adapted from Dr. Frank Allport's Vermont law. 



217 

such examination and treatment to be made by the county physician of the dis- 
trict wherein said child resides; and it shall be the duty of such county physician 
to make such examination and treatment, and if he be unable to properly treat 
such child he shall forthwith report such fact to the county commissioners of tlie 
county with his recommendation. 

Sec. 3. The State Auditor is hereby directed to draw his order for such 
sums and at such times as the State Superintendent of Public Instruction 
may require to carry out the provisions of this act. The total expenses 
under this act shall not exceed one thousand ($1,000.00) dollars in any bien- 
nial period ending November 30th. 

The provisions in italics are the only amendments, made by 
the Senate and concurred in by the House, to the bill as I wrote 
it and as it was introduced in the House by Hon. Alma V. 
Lafferty, the one woman member of the Assembly. 

Section 2, without its amendment, was included in a bill to 
collate the School Laws, introduced in the previous Assembly, 
but failed of passage. 

It is the duty of the State Bureau of Child and Animal Pro- 
tection to promote the interests of all the children in the State, 
to secure the enactment and enforcement of legislation for their 
benefit and to have especial care of the abused, neglected, de- 
pendent, delinquent and defective children. For this reason it 
was made the especial duty of the Bureau of Child and Animal 
Protection to enforce the "Physical Examination (Bates) law," 
at the suggestion of its executive officer, the Secretary, Mr. 
E. K. Whitehead, who has long been particularly interested in 
what might be termed prophylactic child protection. The Bu- 
reau of Child and Animal Protection has endeavored to promote 
the physical welfare of the children coming under its especial 
care, but has been able to do so universally and more effectively 
since the passage of this law. The Bureau has brought several 
prosecutions for failure to conform to the statute but has not 
brought any such cases in the Juvenile Court of Denver. 

The Denver Juvenile Court has a corps of special officers desig- 
nated to look after the delinquent children of this city, but has 
never paid any attention to possible physical defectiveness as a 
cause of delinquency, nor has it made any attempt to remedy 
such defectiveness either by recourse to this law or in any other 
way. 



218 

Before the measure was introduced it had been endorsed without 
suggestion of change by the State Superintendent of Public In- 
struction, Mrs. Katherine M. Cook; the Superintendent of the 
Denver Public Schools, Dr. Charles E. Chadsey; the Executive 
Committee of the State Teachers' Association and the Associ- 
ation itself; the State Ophthalmological Society; the Democratic 
Women's Legislative Committee; and the Colorado Federated 
Women's Clubs' Legislative Committee but none of them had any 
part in its passage. 

There was no real opposition in the legislature but the bill 
happened to present a convenient excuse for filibustering tactics 
and the constant attention it required for safe conduct through 
every possible legislative procedure devolved upon Mrs. Lafferty 
and myself. 

Governor Shafroth promptly signed it, and it went into effect 
in July, 1909. 

The circular letter of instructions on the modus operandi of 
the law, the record blanks, tests, letters to parents, etc., were 
prepared by the then State Superintendent of Public Instruction, 
Mrs. Katherine M. Cook and myself, and they are still in use. 
Tests and blanks in use in other states and cities were consulted 
and adapted to our conditions and purposes. The text thereof is 
as follows, and the Colorado method is best comprehended by 
reading them in their entirety. 

INSTRUCTIONS 

ON THE LAW FOR THE EXAMINATION AND CARE OF PUBLIC 

SCHOOL CHILDREN. 



[Circular Letter.] 

The Teachers will fill out the blanks in the Teachers' Record Cards as 
instructed, using the carbon paper to make two copies at the same time; the 
one marked "Principal or County Superintendent" is to be sent to those 
officials, and the other marked "Teacher's Stub" is to be left in the book for 
subsequent reference, comparison and summary. 

Use a good, sharp pointed pencil with force enough to produce clear copies 
not easily erasible. 



219 

If it becomes necessary to re-record a pupil during the same school year, 
affix the second stub to the stub of first record. 

The Teacher will place a * in red ink after the names of pupils whom she 
considers it desirable or necessary to refer for medical attention in accordance 
with the law, and indicate the reason therefore by a * opposite the number 
in the margin of the Record Card where defectiveness is indicated. 

The Principal or County Superintendent will file the Teachers' Record 
Cards when received with the Notice of Parents' Book. 

The Record Cards of pupils whose parents the Principal or County Super- 
intendent notify are to be attached to the Stub of the corresponding Notice 
to Parent or Guardian, as directed thereon. 

The Principal or County Superintendent will send the Notices to Parents 
or Guardians in accordance with the law (Session Laws of 1909, page 490), 
and record same on the Record Card received from the Teachers. 

Should the Principal or County Superintendent require medical care for 
pupils not advised by the Teacher or not require it of any so recommended, 
he will notify the Teacher to that effect, with date of sending of Notice. In 
lieu of information to the contrary the Teacher will assume that Notices have 
been sent when marked therefor on her Record Card, and will date the 
"reasonable time" allowed for the return of the Physician's Report from the 
date of the sending of the Record .Card to the Principal or County Superin- 
tendent. 

The Physician's Report is to be returned to the Teacher. If within a reason- 
able time the Physician's Report is not received by the Teacher or proves to 
be unsatisfactory; or where in lieu thereof the parent or guardian sends a 
written statement that he has not the necessary funds wherewith to pay the 
expenses of such examination and treatment; the Teacher will send a Failure 
Notice (with such written statement if any) to the Principal or County Super- 
intendent, recording same on the pupil's Teacher's Record Card. 

The Principal or County Superintendent will record the Failure Notice on 
Pupil's Record Card and forward the Notice to the State Bureau of Child and 
Animal Protection, State House, Denver. 

If a written statement of inability to pay accompanies a Failure Notice, 
the Principal or County Superintendent will at once "cause such examination 
and treatment to be made by the County Physician of the District wherein 
said child resides;" who if unable to treat such child shall forthwith report 
such fact to the County Commissioners with his recommendation. If satis- 
factory results are not had within a reasonable time, the Failure Notice, 
written statement of inability to pay, statement of reference to County 
Physician, etc., with other information germane to the case, is to be for- 
warded by the Principal or County Superintendent to the State Bureau of 
Child and Animal Protection. 

What constitutes a "reasonable time" will be left to the judgment of the 
Teacher, under the advice and direction of the Principal or County Super- 



220 

intendent. If, after taking all the circumstances into consideration, doubt 
exists, refer the matter to the Bureau of Child and Animal Protection, with 
full particulars. 

Whatever unpleasant or difficult duty may arise in the enforcement of 
the law for the examination and care of School Children, is laid by the law, 
not upon the Teacher, the Principal, the County Superintendent or the State 
Superintendent of Public Instruction, but upon the State Bureau of Child 
and Animal Protection. 

Whenever the State Bureau of C. and A. P. receives a Failure Notice it 
will at once send its own notice to the Parent or Guardian requesting com- 
pliance with the law, and will, at the same time notify the Teacher of that 
action. 

In most cases a notice from the Bureau will be sufficient to induce prompt 
obedience to the law. If, however, they still "fail, refuse or neglect," the 
Teacher will send a second Failure Notice, marked "No. 2," to the Principal 
or County Superintendent, who will forward it to the State Bureau of C. and 
A. P. at the State House, Denver. The date of the second notice is to be 
recorded also upon the Record Cards. 

When the Bureau of C. and A. P. receives a Failure Notice accompanied 
by a written statement of inability to pay, etc., it will investigate and assist. 

When the Bureau receives a second Failure Notice it will send an officer 
who will first consult with the Teacher, if possible with the Principal or County 
Superintendent, and acting under the direction of the Bureau will take charge 
of the case. 

In most communities there is at least one local volunteer officer of the Bureau 
of Child and Animal Protection, fully empowered to act, and to whom the 
Teacher might be disposed to report cases, unless otherwise instructed. But 
in order to obtain accurate records and for other obvious reasons, Teachers 
are instructed to report all cases in accordance with the directions herein 
prescribed. 

Teachers will record the results of the law enforcement by the State 
Bureau of C. and A. P. upon the pupil's Record Card. 

The Teachers will fill out the Teacher's Summary blanks and mail to the 
County Superintendent at the end of the fall term and at the end of the school 
year. 

The County Superintendents will fill out the County Superintendent's 
Summary blanks and mail to the State Superintendent at the end of the fall 
term and at the end of the school year. 

Record Card Books and all other supplies for the execution of the pro- 
visions of the state "For the Examination and Care of School Children," 
or any part of them are to be sent upon her demand to the State Superin- 
tendent of Public Instruction. 

Teacher should cross out words not needed and fill inblanks when occasion demands. 
All unused blanks should be returned to County Superintendent's office. 



221 

INSTRUCTIONS 

ON 

SIGHT, HEARING, AND BREATHING TESTS 



In Accordance with Chapter 203, Pages 490-491, Sections 1, 2, and 3, Session 

Laws of 1909. 



To Superintendents, Principals and Teachers: 

The examination should be made by the teacher under whose immediate 
observation the child is to be, and under the direction of the Principal, or 
where there is no Principal, of the County Superintendent. 

It is to be made during the first month's attendance of the child during 
each school year. 

Every child must be examined. 

The examination must be made privately and singly. 

The record blanks must be filled out with the data obtained, and kept on 
file. The duplicate is to be sent to the County Superintendent at the end of 
each school term and upon request of the State Superintendent. 

CHART No. I. 

DISTANCE VISION CHART— LETTERS. 

Sight — 

Children already wearing glasses should be tested with such glasses prop- 
erly adjusted; i. e., frames straight, lenses on the same level and not touching 
the eyelashes. The head must be held straight, not tilted, and the eyes must 
look through the centers of the lenses. 

The vision Chart must be kept in this envelope when not in use, as famili- 
arity with it leads to an acquaintance with its letters. When it becomes soiled 
and worn, apply for a new one. Do not cover it with glass. 

Place the Vision Chart on the wall in good light, side light preferred, and 
on a level with the child's head. 

Place the child at a distance of twenty feet from the chart, directly 
facing it. 

Examine each eye separately. Hold a card in front of and close to one 
eye, while the other eye is being tested. 

Press the card against the nose, but not against the covered eye, as pres- 
sure on the eye will induce an incorrect result. 

Have the pupil begin at the top of the chart and read aloud down as far 
as he can; first with the right eye from right to left and then with the left eye 
from left to right. 

The line marked 20 should be seen and read at a distance of twenty feet 
if the child has normal vision. 



222 

To Record the Acuteness of Eyesight: 

The number opposite each line of the Vision Chart shows the distance in 
feet at which those letters should be read by a normal eye. If the eye reads 
the letters (or with a mistake of only one or two letters) on the line marked 
20, the vision is to be noted as 20/20, or normal ; if the smallest letters which 
can be read are on the 30-foot line the vision will be noted as 20/30 (if vision 
is 20/30, parent need not be notified, if child is otherwise in good health) ; if 
on the 40-foot line, as 20/40; and so on. 

If the child cannot see the letters on the 200-foot line, have him approach 
slowly until he can see them. If 15 feet is the greatest distance at which he 
can read them, the record will be 15/200; if 10 feet, 10/200; and so on. 

To prevent memorizing, one letter at a time may be shown, and in irregu- 
lar order, by covering the others with a piece of pasteboard having a hole cut 
in it, large enough to expose one letter. 

CHART No. II. 

DISTANCE ILLITERATE VISION CHART — FIGURES. 

Use this chart in place of the "Distance Vision Chart — Letters" for chil- 
dren who do not know the letters, and in exactly the same way as directed 
for Chart No. I. 

CHART No. III. 

ASTIGMATISM CHART. 

Test for Astigmatism: 

Use the Astigmatism Chart in the same way at the same distance. If all 
of the lines are seen as equally dark and heavy, the child has no apparent 
astigmatism. 

If one or more of the lines are seen to be blacker and heavier than the 
others, the child has apparent astigmatism, and the record should show which 
line is the blackest by its number on the chart. 

Whenever it is learned that the child has less than 20/20 vision in either 
eye, or can see unusually far; that the lines on the astigmatism chart are not 
seen to be of even blackness; that the focusing power is markedly poor; that 
the child habitually tilts the head; that the eyes or eyelids are habitually red 
or inflamed, or sties have existed; that the eyes are crossed or have a strained 
appearance; that headaches of any kind, or pain in eyes or head, follow use of 
the eyes in reading, music-reading, sewing, or other near work with the eyes ; 
that train sick headaches or morning headaches in the back of the head are 
frequent; or that the letters blur or run together when reading; the teacher 
will refer the case to the Principal or County Superintendent, who will send 
a notice to the parent or guardian of the child, that the child's eyes need 
medical attention, as the law requires. Effectual medical attention, with 
properly fitted and properly worn glasses, will cure most of these conditions. 



223 

HEARING. 

Ears: 

All children should be examined. Children should be examined privately 
and singly. 

Examine the ears separately and together. 

Ascertain whether the child has earache, has pus or a foul odor proceed- 
ing from either ear; suffers from frequent "colds in the head;" is subject to a 
constant catarrhal discharge from the nose or throat ; or has noises in the ear. 

Seat the child, with both eyes closed, facing you, near one end of a quiet 
room with the windows closed, and begin the tests of the hearing at a meas- 
ured distance of twenty-five feet. The test is to be made by having the pupil 
close one ear tightly with his finger, while you observe the ability of the child 
to repeat your moderate whispers, with equal emphasis, of numbers between 
twenty-one and ninety-nine, inclusive — avoiding numbers with ciphers. Avoid 
having a wall behind you to act as a sounding board. 

Record the distance at which the child correctly repeats a series of three 
numbers, which gives his hearing distance for that ear, thus : 

If he repeats the numbers correctly at twenty-five feet, his hearing is 25/25, 
or normal; if the child only repeats the numbers correctly at twenty feet, his 
hearing is 20/25; and so on. 

Further tests for ears, thus found defective, can be made by observing the 
greatest distance at which each ear can hear the tick of an ordinary watch. 
The normal distance is at least three feet. 

When the hearing of either ear is found to be defective, the teacher will 
refer the case to the Principal or the County Superintendent, who will at once 
notify the parent or guardian of the child, that the child's ears need medical 
attention, as the law requires. 

BREATHING. 

Ascertain whether the child is a constant or frequent mouth-breather; has 
frequent attacks of tonsilitis or sore throat; has a flat or depressed chest, 
occluded nostrils or difficulty in breathing on exertion. 

To ascertain if the nostrils are occluded, have the child press his fingers 
against one side of his nose and breathe forcibly through the other — note 
whether one side or the other is stopped up. 

If any of these conditions exist, or are of frequent recurrence, the teacher 
will refer the case to the Principal or County Superintendent, who will notify 
the parents or guardian of the child, as the law requires. 



224 

COLORADO PUBLIC SCHOOLS. 
RECORD CARD. 

Date 



teacher's tests of sight, hearing, breathing, and mental, moral and 
physical defectiveness. 

City or Town County School 

Principal's Name .Teacher's Name 

Superintendent's Name 

Pupil's Name 

Age Sex Nationality 

Parent's or Guardian's Name Address 

From 4 to ii underline in ink the points that apply to this pupil. 

i . Sight 

Glasses used — Yes, No 

Hearing 



Breathing 

Mental Activity (Good Average Slow ) 

Mental Defectiveness i. Inattentive. . . .2. Backward. . . . 

3. Imbecile 

Frequent Absences Cause - 

Moral Defectiveness Vicious personal habits 

Moral delinquencies 

Physical Activity (Excessive Average Poor ) 

Posture 10. Vaccination — Yes, No 

Physical Defectiveness — Under- or over-development, uncleanliness, 
twitchings, limping, deformity, head tilting, offensive breath, skin 
eruptions, frequent colds, hoarseness, cough, nasal voice, pain in 
head, hip or knee, headaches, backaches, signs of fever, signs of 
contagious diseases, pallor, poor circulation, teeth (crooked, promi- 
nent, decayed, dirty), frequent urination, enlarged glands, stutter- 
ing. 
Indicate marked Mental, Moral or Physical Defects. 

Disposition of this Case 

(a) Parent or Guardian notified Date 

(b) Examination instituted Date 

(c) Result Report of Physician returned. 

(d) State Bureau of C. and A. P. notified 

(e) Remarks 

These "Record Cards" on sheets, in pairs, are made up in pads, a carbon sheet being 

used between each pair. 

The first of each pair bears the following footnote: 

This sheet is to be sent by the Teacher to the Principal, or where there is no Principal, 
to the County Superintendent. 

The second, being the carbon duplicate, has the following footnote: 

Teacher's Stub — Retain for Reference. 



225 

PRINCIPAL'S OR COUNTY SUPERINTENDENT'S STUB. 
To this stub attach for permanent record, when received, the Duplicate 
Record Card of the Teacher's Test of Sight, Hearing, Breathing and Mental, 
Moral and Physical Defectiveness, from which make up the reports to the 
Superintendent of Public Instruction, to the State Board of Child and Animal 
Protection, and the notification letter to parent or guardian. Sections 58730 
and 5995a, School Laws of the State of Colorado, 1909. 

STATE OF COLORADO. 
NOTICE TO PARENT OR GUARDIAN 

THIS NOTICE DOES NOT EXCLUDE THE PUPIL PROM SCHOOL. 

THIS NOTICE EXCLUDES THE PUPIL FROM SCHOOL FOR WEEKS. 

School Town County 

19 

Mr 

Your child, , has been examined accord- 
ing to Sections 58730 and 59950, School Laws, '09, and it is found that 

*sight, hearing, breathing, seem to be defective, and we advise that the child 
be taken to a competent physician for examination and treatment. 

If this notice with a satisfactory report from the physician employed 
is not returned to the child's teacher within a reasonable time, it will be con- 
sidered as failure, refusal or neglect to comply with the law, which will neces- 
sitate report of the same to the State Bureau of Child and Animal Protection. 

In case of contagious disease, the pupil will be excluded from school 
in accordance with the rules of the State and local Boards of Health. 



Principal. 
Co. Superintendent. 



Date of Notification of Parent or Guardian 

Examination Instituted 

Treatment Begun 

Result to Child 

Date of Notification of State Bureau of Child and Animal Protection. 
Remarks : on further course of case 



REPORT OF PHYSICIAN. 
Town County Date 19. 



Teacher. 
*Cross off words not needed. 



226 

Dear Sir: Madam: 

I have examined in accordance with 

your recommendations and find the following conditions, and have instituted 
the treatment as noted: 

Eyes 

Ears 

Nose 

Throat 

Teeth 

Spine 

General Conditions 

Contagious Disease 

Diagnosis 

Remarks : 



Respectfully, 

Physician. 
Address. 

Attach to Original Teacher's Record when returned. 

Physical Examination Report to Superintendent oe Public Instruc- 
tion. 



Male. Female. Total. 



Enrolment 

Number of pupils examined 

Number of pupils with defects of sight. . . . 
Number of pupils with defects of hearing. . 
Number of pupils with defects of breathing . 

Number of pupils with mental defects 

Number of pupils morally defective 

Number of pupils physically defective other 

than enumerated 

Total number of pupils with one or more 

defects 



Superintendent of Schools. 
191 ... of County. 



227 

From the Biennial Report of the State Superintendent of 
Public Instruction, 1 909-1 910, Mrs. Katherine M. Cook. 

Physical Examination : 

Among several worthy laws concerning schools, enacted by the Seven- 
teenth General Assembly, no one was of greater importance for the pro- 
tection of children than that concerning the physical examination of children. 

While the returns are incomplete and not wholly accurate, owing to un- 
familiarity of teachers with the law and its provisions in this, the first year 
of its existence, they are sufficiently complete and reliable to give a fair idea 
of its importance. 

The report is tabulated by counties, and will be found among statistics at 
end of this volume. Out of the sixty counties in the State, Dolores, Garfield, 
Kiowa, Larimer, Park and Washington failed to make any return. The Law 
was not complied with by the superintendents, principals and teachers of 
these counties, and the children in their schools are not included in the totals. 

In the remaining fifty-four counties 108,798 children are enrolled. Of this 
number 92,427 were examined, with the result that 41,546 were found de- 
fective physically, mentally or morally to a degree sufficient to warrant re- 
porting their condition to their parents, in accordance with the terms of the 
law. 

Surprising as this result is, and certain as it is to be received with incredulity 
by all who have given the matter little or no attention, it is still short of the 
percentage of defectives found elsewhere. It must be remembered that this 
examination is pretty thorough and searching, and covers defectiveness of 
any kind, which in many cases might go unnoticed for years, even by the 
parents of the children. This is especially true of the sight, hearing and 
breathing tests. The law provides that especial attention be paid to the eyes 
ears, nose, throat, teeth and spine. If defectiveness were looked for in no 
other organs, and if mental and moral defectiveness were left out altogether, 
the number of children found defective would very nearly equal the total 
found. In fact the returns show that sight, hearing and breathing alone 
would account for nearly all of them. The number of adults who have per- 
fect sight, perfect hearing, and whose air passages are in normal condition is 
very small, indeed; and while the proportionate number of children normal 
in these respects is higher, it is much lower than most people suppose. 

The returns from Colorado show 45 per cent, of defectiveness in the chil- 
dren examined. In Chicago, out of 123,897 children examined, 51 per cent, 
were found defective; in Kansas City 56 per cent, were found defective. 

Out of the 41,546 children found defective in Colorado, defects of sight 
existed in 26,978, hearing in 6,155, breathing in 8,045, an d other unclassified 
defects, 21,825. There were 3,071 mental defectives and 746 moral defectives. 

In Chicago 32.3 per cent, had defective teeth, 20 per cent, enlarged tonsils 
and 15.9 per cent, defective vision. In Colorado 29.1 per cent, had defective 



228 

vision, a difference which our brilliant sunshine and frequent dust storms 
may perhaps account for in part. 

In Colorado 6.6 per cent, had defective hearing and 8.8 defective breathing. 

It was found in one school in Denver, the only one in which such a record 
was kept, that the teachers' examination made under the directions from 
the Superintendent of Public Instruction, was confirmed by the physician's 
diagnosis in ninety-eight per cent, of the cases discovered by teachers and 
reported to the parents for medical examination. If a like degree of accuracy 
or anything approaching it was reached in the rest of the schools hardly 
anything better can be asked. 

Without going further into an analysis or comparison of the results ob- 
tained than to say that they show for the first year a value and importance 
not merely justifying the law, but fixing its place as a permanent part of our 
school law not less in importance than the instruction for which our schools 
have heretofore existed, it may be said that Colorado is far in the lead of any 
other state or country in the world. England is the most progressive foreign 
country in this respect, yet she ranks below Massachusetts, and the superiority 
of the Colorado law over that of Massachusetts is so great as to be prac- 
tically out of comparison. 

Out of the 41,546 cases of defectiveness reported to the State Superintendent 
of Public Instruction as having been discovered, and presumably reported 
to the parents of the children, 221 cases were reported by teachers to the 
State Bureau of Child and Animal Protection for failure of parents to have 
the medical examination indicated by the teachers' examination made. 
Whether this was the total number of cases which should have been reported 
we have no means of knowing. In the absence of further information it may 
be assumed that it does not depart far from the total which should have been 
referred. 

With one exception the parents in all these cases were induced by letter 
or by the visit of an officer to do whatever the children's condition required. 
In the one case where it was necessary to bring the parents into court the 
child's throat was nearly closed by enlarged tonsils and his health seriously 
affected. At the trial the father was sentenced to thirty days' imprisonment. 

Owing to the failure of some superintendents, principals and teachers 
to comply with the law and the reluctance of others to do so the instructions 
of the State Superintendent of Public Instruction this year contain the fol- 
lowing paragraphs: 

"The requirements of the law providing for the examination and care of 
children in the public schools are mandatory upon teachers, principals and 
county superintendents. 

"In all cases where teachers, principals and county superintendents fail, 
neglect or refuse to comply with the terms of the law it will be the duty of 
the State Bureau of Child and Animal Protection to enforce against them the 
provisions of the following sections of the law for the protection of children: 



229 

" 'It shall be unlawful for any person having the care or custody of any child 
wilfully to cause or permit the life of such child to be endangered, or the 
health of such child to be injured, or wilfully to cause or permit such child 
to be placed in such a situation that its life or health may be endangered 
* * * or in any other manner injure such child. 

" 'Any person who shall be convicted of violating any of the provisions 
of the preceding section of this act shall be fined not exceeding one hundred 
dollars, or be imprisoned in the county jail not exceeding three months, or 
both, in the discretion of the court; and upon conviction for a second or any 
subsequent offense shall be fined not exceeding two hundred dollars, or be 
imprisoned in the county jail not exceeding six months.' " 

A quantity of informative circulars, one on the care of the teeth, prepared 
by the Denver Dental Association, and one on the care of the eyes, ears, nose 
and throat, prepared by the Humane Education Society, Denver, were sent 
to the county superintendent of schools, accompanied by the following letter: 



STATE OF COLORADO 

DEPARTMENT OP PUBLIC INSTRUCTION. 

DENVER. 

February 14, 19 10. 
To the County Superintendent of Schools : 

I am sending some circulars on the physical care of children, prepared by 
the Humane Education Society and Denver Dental Association. They are 
for general distribution. It is hoped, by those who have issued them, that 
they will prove of some assistance in the enforcement of the new law on the 
physical examination and care of children in our public schools. 

Respectfully, 

Katherine M. Cook. 

The circulars mentioned have, also, been incorporated in the State course 
of study. 

While we were somewhat lenient in the enforcement of this law, during 
the past year, because of its newness and the fact that parents and teachers 
were both unfamiliar with its provisions, I believe it should hereafter be 
rigidly enforced, and I feel the utmost confidence in the ultimate good to be 
accomplished thereby. 



office of the state superintendent of public instruction, 
denver, colorado. 

CARE OF THE TEETH. 



Teeth that Are Well Cared For Are Beautiful as Well as Useful. — Their chief 



230 

use is to prepare the food for the stomach — to grind the food and mix it with 
the saliva. Food that is not thoroughly chewed causes indigestion and con- 
stipation. 

Teeth Should Last to the End of Life. — If they do not it is due to decay or 
loosening. 

Decay is caused by acids, formed from bits of food left after eating, along 
the edge of the gums, between the teeth, and in the crevices of the grinding 
surfaces. 

Loosening of the Teeth is Caused by Diseased Gums. — Tartar is the chief 
cause of diseased gums. Swollen and bleeding gums are diseased gums. 
The way to prevent decay and loosening of the teeth is to keep them clean. 
The general health will be better if the teeth are kept in good condition, so 
that the food can be thoroughly chewed. 

// Children Are Taught to Chew Their Food Thoroughly Their Teeth Will 
Grow Strong and Healthy. — Teeth can best be kept clean by scrubbing with 
a fairly stiff brush, with bristles well apart, to reach between the teeth, and 
some good powder or paste. Scrub all sides of the teeth, and in all directions, 
for at least two minutes, night and morning. 

Irregularities of the teeth should receive careful treatment, especially those 
which make it impossible to close the teeth properly, thus leading to poor 
digestion and mouth breathing. 

The First Permanent Molars Are the Most Important Teeth in the Mouth. — 
They come at about the sixth year, and are located right back of the tem- 
porary or "baby" teeth, and are often neglected because they are mistaken 
for temporary teeth. 

The Temporary Teeth Should Last until the Permanent Ones Come In. — Any 
that decay before that time should be filled. This is necessary to the good 
health of the child. As good care should be taken of the temporary teeth 
as of the permanent ones. Too early extraction of the temporary teeth 
is a cause of deformities of the mouth. 

A Dentist Should Carefully Examine the Teeth at Least Twice a Year. — A 
bad condition of the throat, the nose and the ears is made worse by decayed 
teeth. They add to the chances of catching infectious diseases. Well cared 
for teeth and a clean mouth help prevent Tuberculosis. 

CLEANLINESS IS THE BEST GUARD AGAINST DISEASE. 



PREPARED BY THE DENVER DENTAL ASSOCIATION. 



EARS, NOSE AND THROAT. 
The Sense of Hearing is Very Valuable to Every One. — Although each person 
has two ears well protected in dense bone, they are readily reached by diseases 
that attack the lining membrane of the nose and throat, such as colds, la 
grippe, measles, scarlet fever and diphtheria. 



231 

The ears are connected with the throat by two gristle-like tubes. It is 
through these tubes that air is forced into the middle ear cavities during the 
act of swallowing. For good hearing there must be air in the middle ears to 
balance the air pressure from without. 

There is a pair of glands, called tonsils, one on either side of the root of the 
tongue, and also naturally (normally) a small tonsil-like mass called adenoids, 
in the upper part of the throat, close to the tubes leading to the ears. 

When either the tonsils or the adenoids become too large, they interfere with 
the air entering the tubes to the ears and with the circulation of the blood 
to and from the ears. As a result the hearing becomes dull, especially when 
the child has a "cold." Repeated "colds" bring about lasting dulness of 
the sense of hearing. 

Children with Earaches Almost Always Have Adenoid Growths. — Earaches 
should have prompt and proper care for they may result in deafness or in 
serious disease of the bone in which the middle ear is located. 

"Running Ears" are Diseased Ears. — If neglected they result in damaged 
hearing and are a source of danger to life. All such ears should be kept clean 
and have proper treatment. 

Nasal breathing is not only necessary for the preservation of hearing, but for 
the general health. It is known that even in dogs when nose breathing 
becomes impossible the hair falls out, the skin grows wrinkled and asthma 
sets in. And the same thing happens to the puppies born when the mother 
dog is so affected. 

Bony deformities and other growths inside of the nose may also prevent nose 
breathing and, like tonsils and adenoids, by causing mouth breathing, give 
rise to deformities of the upper jaw, irregular teeth and to a number of ner- 
vous troubles and diseases, such as St. Vitus' dance, night terrors, headaches, 
restlessness, night sweats, mental dulness, backwardness in school, asthma, 
rheumatism and tubercular glands of the neck. 

Mouth breathers are more liable to contagious diseases and to diseases of the 
bronchial tubes and lungs, which are more apt to be fatal than in nose breath- 
ers. 

Practically all of the causes of mouth breathing are curable, and the earlier 
they are removed the easier it is for the child to overcome the "mouth breath- 
ing habit." 

(Information for parents. Prepared for the Humane Education Society, 
Denver, by Drs. Wm. C. Bane, Osee W. Hoffman and Mary E. Bates.) 



, EYES. 

Eyes are necessary for self-protection and to make a living, yet they are the 
least cared for and the most abused part of the body. 

Eye-strain is an excessive or abnormal effort of an eye or a pair of eyes to 
maintain perfect vision (sight). 



232 

Eye-strain is due chiefly to some defect in the shape of the eyeball or to weak- 
ness of the muscles of the eyes. It may also be due to or made worse by 
over-use or unwise use of the eyes. 

A perfect eye can be strained by over or unwise use just as a perfect arm or 
leg can be. There are few perfect eyes. 

The Imperfect Eyes Are on a Strain Whenever Open. — They are more easily 
harmed by over or unwise use. This means a leakage of nerve force in the 
eyes and in other parts of the body. Such eyes may seem to be perfect and 
yet by using up more nerve force than their share, in order to see, may lead 
to diseases in other parts of the body thus deprived of nerve force. 

Slight imperfections of the eyeballs causing small amounts of eye-strain often 
do more harm by continuously undermining the general health than do the 
greater ones that are more readily felt and hence more quickly relieved. 

Reading while lying down, and by poor light, night or day, is harmful to the 
eyes. 

SOME BAD EFFECTS OF EYE-STRAIN. 

Headache and neuralgia, particularly over the brows and in the back of the 
head and neck. 

Inflammations: redness, scales, crusts and sties of the eyelids and ulcers 
of the eyeball. 

Cross-eyes: the eye that crosses usually loses vision from non-use and may 
become practically useless if not corrected. 

"Reflex" Nervous Conditions: epileptic spasms, convulsions, "nervousness," 
restlessness at night, palpitation of the heart, St. Vitus' dance, nausea, 
vomiting, indigestion, a "run down" and even more serious physical con- 
ditions are common. 

Watering of the eyes and blurring, when reading, sewing or doing other 
near and fine work. 

Backwardness in Mental Growth, and Truancy. — Eye-strain produces an 
irritation in the brain expressed by a restless desire to run away from school 
(and near work) and then they stay away for fear of failure in class. 

Tilting of the Head. — When constant, this is often due to an effort to 
straighten out crooked vision and may lead to spinal curvature with its bad 
effects. 

Holding the work close to the eyes shows eye-strain. 

When these conditions are caused by defects in the eyeballs, glasses are 
necessary and they cannot be permanently cured without glasses. 

Children's eyes should always be tested with pupils dilated by atropine 
(belladonna). 

Spectacles are better than nose glasses. 

It is as necessary to keep the glasses on straight as it is to have a proper fit. 
If glasses are not comfortable or do not fit they will be taken off and not 
worn. Because a child refuses to wear the glasses it is no sign that he does 
not need properly-fitting spectacles. (Prepared for the Humane Education 
Society by Dr. Wm. A. Sedwick and Dr. Mary E. Bates.) 



233 

The following leaflet was prepared for use in the Denver Public 
Schools by one of the Denver School Inspectors, Dr. Rose Kidd 
Beere, and in connection with it the notice following thereafter is 
used: 



DENVER PUBLIC SCHOOLS. 
School District Number One in the City and County of Denver, Colorado. 



NOTICE TO PARENTS. 

We ask your help in the effort we are making toward the education of 
the children in the care of the teeth. 

Much bad health comes from decayed, unclean teeth. 
Your Part: 

To see that your child brushes his teeth after every meal. 

If he has decayed teeth, take him to a dentist. 
Our part: 

To give proper instruction on the care of the teeth. 

To provide tooth brushes for 7 cents. 



Food left about the teeth decays and forms lactic acid which destroys 
the enamel. 

Green stain, if not removed by a dentist, should be brushed persistently 
using precipitated chalk, occasionally powdered pumice stone. 

The temporary (baby) teeth should be kept filled and in place until 
gradually pushed out by the coming second teeth, for if lost too early those 
taking their places are apt to come in crooked. 

The sixth year molar often begins to decay early. It is the sixth 
tooth from the middle line, on each side, above and below. Watch it and 
have it filled if it shows a spot of decay, for no tooth will ever come in its 
place if it is lost. 

Teeth should be examined every six months. 



DENVER PUBLIC SCHOOLS. 

School District Number One in the City and County of Denver, Colorado. 
To the Parent or Guardian: 

An examination of your child indicates that the child's teeth need at- 
tention. 

I suggest that a dentist be consulted. 



The dentist who examines this pupil is requested to sign and date this 



234 

card and return it to the child, who will return it to the teacher. A subse- 
quent report of the result of this treatment will be appreciated. 

Principal. 

I have this day examined the above named pupil and have begun treat- 
ment. 

Date 

D. D. S. 



Any law which adds to the requirements and duties of the 
teacher may meet with her opposition if she be ignorant of its 
need, its objects and its benefits; if she be blind to its absolute 
and relative importance and, indifferent to her true mission and 
opportunity, determined to earn her salary the easiest way. 

When schooling ceases to be the present senseless routine of 
imparting and receiving a hodge podge of miscellaneous infor- 
mation and becomes a truly educative process the physical welfare 
of the pupil will be recognized as the prerequisite of successful 
mental, moral and spiritual development. 

The demand which the "Bates Law" for the Examination and 
Care of Public School Children has created for a better under- 
standing of mental, moral and physical defectiveness and their 
inter-relations has shown the need for the special instruction 
of teachers therein as well as their special training in the methods 
of examination and the enforcement of the law. 

The State Bureau of Child and Animal Protection has kept 
Dr. W. R. Callicotte, Professor of Moral and Humane Education, 
in the field throughout the state for that purpose where such 
instruction has not been furnished by other authority, and the 
State Normal School at Greeley has added to its curriculum such 
a course which will be given by Dr. Callicotte. Proficiency in 
performance of her part in the law will doubtless soon become 
mandatory before a would-be teacher can obtain her certificate. 

In Denver, during the present school year, the Denver School 
Board has employed two "School Inspectors" who have supple- 
mented the work of the teachers where the teacher found de- 
fectiveness. This has operated to the better protection of parents 
from needless recourse to a physician and a better differentiation 



235 

and comprehension of defectiveness, as well as a training of the 
teachers in their duties under the law. The discovery by Dr. Beere 
of scores of cases of trachoma in the public school maintained 
by Denver in the State Home for Dependent and Neglected 
Children, was one of the benefits of this additional medical in- 
spection, as desirable in its way as the release of the teacher from 
her responsibility by a purely medical inspection would be un- 
desirable. 

As a state proposition paid medical inspection by physicians 
is at present a financial impossibility. None of the many valid 
objections to possible political incompetents as such inspectors 
apply to the Colorado method. 

Here the benefits are not limited to the examination made at 
the beginning of the school year, for ours is a system of con- 
tinuous observation, including both prophylaxis and cure. 

The foolish and vicious trend of the times promoted by the 
Juvenile Courts and other influences, to relieve parents of their 
obligations and responsibilities to their children, and to the com- 
munity for the welfare of their children, by assuming such obli- 
gations and responsibilities or placing them elsewhere, and the 
equally foolish and pernicious doctrine that, per se, "parents know 
what is best for their own children" and will therefore, do what 
is best for them, find no support in the "Bates law." 

The law was designed to fit conditions in Colorado; to utilize 
the public school system in a proper and available way; to obtain 
at a minimum cost a practically continuous observation and in- 
vestigation of the health and needs of school children; to hold 
parents responsible for the relief and cure of defectiveness in 
their children; to permit them freedom of choice of a "competent 
physician or surgeon;" to furnish information to parents of value 
to them, their children and the community; to assist them wher- 
ever necessary for the best good of the children and to provide a 
legal way to compel delinquent parents to meet their legal paren- 
tal obligations and responsibilities. 

The following letter presents the subject from the standpoint 
of the law's enforcement by the Bureau of Child and Animal 
Protection. 



236 

The State Bureau of Child and Animal Protection. 
State Capitol, Denver. 

Denver, Colo., March 17, 1912. 
Dr. Mary Elizabeth Bates, 

520 Majestic Bld'g, Denver. 
My dear Doctor: 

There are no general statistics available on the operation of the law re- 
quiring the physical examination of school children later than those furnished 
by the State Superintendent of Public Instruction in her biennial report for 
1909-1910. They covered the first year of the law's enforcement, it having 
been passed in the spring of 1909. The next biennial report of that office 
will appear in January, 19 13, and will be for the years 1911-1912. 

However, the statistics in the report for 1909-19 10 will answer the pur- 
pose of determining the value of the law and its practical working. We 
have no reason to expect any considerable changes in the next report except, 
probably, a more complete and intelligent observance of the law by teachers. 
There is no question of its being a permanent and most valuable addition to 
school legislation and of its broadening from year to year the narrow view 
heretofore held of what the school and the teacher ought to do for the child. 

Not so many cases of neglect or refusal by the parents to act upon the 
teacher's notice were referred to this office the second year as the first. As 
might be expected, few such cases came from places which furnished many 
the first year, and vice versa. We have no reason to think this is due to lax 
observance of the law but rather to general acquiescence and compliance 
with it. Some towns where teachers and principals are known to be thor- 
ough-going and alert report no difficulty in any case. 

We have thus far had only three cases where our officers found it necessary 
to bring parents into court under the general law against wrongs to children 
for refusing to have examination made and treatment begun after notice 
from the teacher. In two of these cases the parents were convicted and given, 
each, a thirty-day sentence in jail, which they escaped serving by complying 
promptly with the law. The third case has not yet been tried but we expect, 
without doubt, to convict. 

It should be said that this Bureau makes all reasonable effort to secure 
compliance of parents with the law without court action. When teachers 
notify us of the failure of parents to respond to their notices of apparent 
defective conditions in their children we, in our turn, notify the parents that 
they must comply with the law within ten days or give some good reason 
for not doing so. At the same time we send a notice to the teacher and ask 
to be informed about all who do not act upon our notice within the ten days. 
At the expiration of ten days if the teacher has not notified us of proper 
action by the parents we send our officer to the delinquents. In all the cases 
we have thus far had, now probably approaching a thousand, we have se- 



237 

cured compliance with the law in all but the three cases already referred to 
without going into court. 

After an experience of nearly three years we can suggest no necessary 
amendments to the law under the conditions existing in this state. 

In our opinion the law in usefulness and value occupies the front rank, 
sharing it with the general law forbidding and punishing wrongs of any kind 
to children, the compulsory education law and an adequate law requiring 

moral and humane education, these four. 

Sincerely, 

E. K. Whitehead, Secretary. 

The object of this law was to provide a way by which all the 
public school children of Colorado might be under continuous, 
intelligent and interested observation with the view of aiding 
them to achieve the highest possible degree of physical, mental 
and moral health, and to provide adequate means for enforcing 
such attention and care by parents as might be necessary therefor. 

The experience of the three school years that have elapsed since 
the law was passed indicates that this object is being attained. 



XXIII. 
THE IMPORTANCE OF EARLY RECOGNITION OF SURGI- 
CAL AFFECTIONS IN CHILDREN. 

By Charles D. Lockwood, M.D., Pasadena, Cal. 

No more important step has been taken in the progress of our 
public schools than that in the direction of improved health 
through school inspection. It will doubtless take several gen- 
erations to overcome entirely the opposition of the ignorant and 
the fanatical in matters of health and hygiene. So strong is the 
fetich of personal rights, and so arrogant the assumption of indi- 
vidual freedom on the part of the average American citizen, that 
he is slow to recognize the right of the city or state to exercise 
control over such personal and private matters as those concern- 
ing his health. The hope of the future lies in teaching in a 
graphic manner to the school children of to-day the fundamental 
facts of biology, physiology, bacteriology and hygiene. 

While school inspection has done much toward discovering 
the causes of backwardness and underdevelopment in children, 
there still remains much to be done. Parents and teachers of 
average intelligence are ready to acknowledge the important bear- 
ing of eye, ear, nose and throat troubles upon the intellectual pro- 
cesses of children, and they even recognize the symptoms pointing 
to these affections. But there is not the same readiness to admit 
the importance of certain other less obvious medical difficulties 
and not so easily recognized surgical conditions. It is of the 
latter that I wish chiefly to speak. 

There are certain glaring defects such as cleft palate, hare lip 
and club foot which cannot escape detection even by the most 
casual observer, and yet they are allowed to go uncorrected 
until the child's life is irreparably damaged by them. These 
congenital defects although rare, when compared to the less im- 
portant throat diseases referred to above, are yet so common that 
there is scarcely a community however small it be that does not 
harbor at least one child who is afflicted with one of these de- 
formities. Children born with hare lip are commonly thought to 



239 

be mentally defective and are often derided by their playmates 
and made the butt of fun and cruel jokes. As a matter of fact, 
these children are almost invariably bright, normal children so 
far as their nervous development and mental faculties are con- 
cerned, and if their deformities are remedied by timely surgical 
aid, they become normal children and grow into useful citizens. 
However, if the dreadful incubus of deformity is not early removed, 
they become most pitiable objects, condemned to unhappy lives. 
The objects of pity, ridicule or disgust, they soon become self- 
conscious, shun all associations and drift into the army of in- 
competents. There should be some provision of the state whereby 
such children should receive timely aid. The children of those 
who are too poor or too ignorant to seek aid should be furnished 
competent surgical attention per force, and free of cost if cir- 
cumstances justify it. The rich, no matter how sceptical they 
may be of the efficacy of surgery, will rarely hesitate long in 
seeking aid. The same attitude should be assumed with reference 
to club-foot, congenital dislocation of the hips and other minor 
physical defects amenable to surgical treatment. In no other 
way is it possible to conserve the lives of such children and to give 
them an equal chance with their fellows. 

There is another large class of surgical affections not so readily 
recognized and yet of almost equal importance as regards the 
efficiency of the child. Among these may be mentioned the fol- 
lowing: (i) Glandular affections. These are often amenable 
to medical treatment, but in a good proportion of cases there is 
some chronic infection, such as tuberculosis or infected tonsils 
which only surgery can relieve. 

(2) Tuberculosis of bones and joints. There is no pathologic 
condition in children that is so often overlooked and in which 
early treatment means so much as tuberculosis of the joints and 
bones. I am constantly seeing cases that have already passed 
the stage when judicious treatment might have saved months 
in bed, loss of function and mutilating operations. The most 
common of these affections are hip- joint disease and Potts' disease, 
or tubercular spondylitis. The early symptoms of these are so 
characteristic that no observant physician should overlook them. 



240 

The presence of muscular rigidity, a limp and night cries should 
always awaken suspicion. With a history of these symptoms, 
the diagnosis can easily be confirmed by examination. 

(3) Chronic appendicitis. Many of the obscure digestive 
troubles in children, indeed I believe the majority of them, are 
dependent upon inflammatory conditions in the appendix. Ow- 
ing to the relatively high position of the appendix vermiformis 
in children and its free mobility, the pain may be referred to any 
part of the upper abdomen, and muscular rigidity will not be so 
marked in the right iliac fossa region as in adults suffering from 
appendicitis. The existence of appendicitis in children is usually 
announced by a severe acute attack, accompanied by exquisite, 
sharply localized tenderness, high fever and a high leucocyte 
count. The association of appendicitis with tonsilitis should 
be constantly borne in mind. Many times the appendix would 
better have been removed than the tonsils. 

(4) Phimosis and paraphimosis. No minor affection of children 
has a more important bearing upon the health and morals than 
these conditions in boys. A tight foreskin with its attendant 
irritation leads to incontinence of urine, hernia, masturbation and 
in young children to convulsions. The records of Juvenile Courts 
also bear testimony to the startling effect of genital irritation 
upon the moral conduct of boys. Circumcision is a simple, safe 
and certain remedy. 

It is hardly to be hoped that these surgical conditions will 
come within the scope of school inspection. The antagonism of 
the public to thorough and complete physical examinations and 
the limited time and facilities of the school examiner will preclude 
the detection of any but the more obvious difficulties. The 
early recognition of these affections will fall upon the general 
practitioner, and it will be necessary both to teach parents the 
necessity of having their children examined for slight ailments, 
and for physicians to cultivate the habit of observing the children 
of the families whom they serve. It has been the purpose of this 
paper to simply point out the importance of early diagnosis in 
surgical conditions as a factor in the conservation of the health of 
children. 



XXIV. 

THE TEACHER'S RELATION TO HEALTH SUPERVISION 

IN SCHOOLS. 

By Ernest Bryant Hoag, A.M., M.D., Department of Hygiene, University of California. 

When medical inspection of schools was first introduced about 
seventeen years ago in New York, Boston, and Chicago, it in- 
cluded an examination for transmissible diseases only. After 
ten years of this sort of work it was found that while the detection 
and control of these diseases was most important, that a vastly 
more urgent phase of health work was being entirely overlooked. 
This is the physical examination of children for various defects 
which interfere with the pupil's health, happiness and progress, 
such as those of the eyes, ears, nose, throat, teeth, heart, lungs, 
and nervous system, and general disorders of nutrition. More 
recently we have come to realize that mental conditions must 
receive as careful consideration as those affecting the physical 
nature of the child, and accordingly school medical officers who 
recognize their full duty have been obliged to familiarize them- 
selves with certain phases of psychology, psychiatry, general 
neurology, and other related branches, which in the past have 
received scant attention from any except specialists in the medi- 
cal profession. 

Beginning then with inspection for transmissible diseases only, 
the field of medical inspection in schools had gradually but 
steadily broadened until to-day a properly qualified officer for 
schools must of necessity be a trained specialist in his particular 
branch. The time has passed when any medical man can be 
considered good enough for the position of health officer in schools 
and particularly any medical man who is either too young, too 
old, or too inefficient to succeed in regularly established lines of 
medical practice. 

But with the increasing demand for better qualified men in 
the schools, and with a rapidly broadening development of the 
work itself, there have also appeared certain factors and factions 
antagonistic to the success of health supervision of school chil- 



242 

dren. These must be reckoned with or the work is doomed to 
failure or at least to many serious set backs. 

Among the most important of these elements unfavorable to 
the proper development of health supervision may be included 
the following: 

1. Ignorance of the nature and scope of the work. 

2. Prejudice. 

3. Expense. 

Within the first division (Ignorance) are naturally included 
many persons who have no adequate conception of what the 
existing physical conditions are among school children. This 
class can be dealt with only by slow patient attempts to inform 
them by means of popular education. 

In the second group (Prejudice) are found individuals belonging 
to several sub-groups which might be classified as follows: 

(a) The Christian Scientists. 

(b) The League of Medical Freedom. 

(c) The "Paternalistic," or those who regard any attempts to 
safeguard their children's health as a personal interference with 
parental rights. 

Within these sub-divisions in the second group (Prejudice) 
are included many admirable individuals in almost every com- 
munity who have strongly established organizations, and who 
are consequently in a position to do much injury to the cause 
of health work in schools. 

Under the third group (Expense) many serious difficulties are 
encountered. In this connection it may be said that with the 
development of what is really a new specialty in medicine, ac- 
companied by a demand for reasonable remuneration, medical 
inspection in schools has received another blow, for schools are 
very slow to realize that even high-priced inspection is a matter 
of economy in the end and it will take considerable time and 
organized effort to make this clear in most communities. 

In the meantime, health supervision is just as urgent a matter 
as ever and some means must be devised to carry it forward. 

Under the existing conditions the most natural method of secur- 



243 

ing proper physical attention to defective school children must 
of necessity originate through the efforts of the teacher herself. 

Whether a school has medical inspection or not, the teacher 
after some elementary instruction can do very effective work. 
Where a medical officer is in general charge, he must necessarily 
depend to a large extent on the teacher's aid if he is to accom- 
plish much. It is too much to expect one medical officer to 
properly supervise the physical conditions of six or seven thou- 
sand pupils or more, or a few medical men to care for fifteen to 
fdty thousand as is often if not usually the case. On the other 
hand, with the teachers as properly qualified assistants, one or 
a few medical officers may easily handle a very large number of 
children in a town or city. 

As things stand to-day practically every city, town, or country- 
district, whether medically inspected or not, finds itself in need 
of the assistance of the teacher in matters pertaining to school 
health. 

How then may teachers become either (i) independent health 
supervisors, or (2) able assistants to school medical officers and 
nurses? The problem is rather an easy one to solve and the 
following plan is now offered as a reasonable solution: 

(1) Every teacher before certification should be obliged to 
give evidence of practical elementary knowledge of the functions 
of the body. 

(2) Every such teacher should be obliged to give evidence of 
practical knowledge of those ordinary physical defects of children 
in the schools, which interfere with school progress. 

(3) Every Normal School and Teacher's College should pro- 
vide adequate instruction in the lines indicated above. Very- 
few of them now do so, although when questioned most of them 
answer in the affirmative, regarding certain traditional courses 
in Biology and Physiology as covering the requirement, a sup- 
position which the facts prove almost entirely unwarranted. 

(4) Teachers who are without experience in Child Hygiene 
but who are already certificated, should be instructed by prop- 
erly qualified specialists in this subject. 

(5) Physical educators must receive this special training in 



244 

addition to that which, the)' - ordinarily acquire in their courses, 
and with it their efforts will prove particularly valuable in this 
new sort of health supervision. 

As a suggestion of what any intelligent and willing teacher 
may accomplish who has received the very elementary training 
in Child Hygiene indicated above, the following outline for a 
non-medical examination or Health Survey is proposed. 

In making this Health Survey the teacher may take her own 
time. If a survey is completed in a room of the average number 
of twenty to forty pupils, in a month or six weeks, it will be quite 
satisfactory, and any teacher will be able to accomplish this with- 
out feeling that she is imposed upon. After a pupil's health 
survey is made a notice should be sent to the parent in those 
cases where physical difficulties appear to exist. This notice 
may be very general and non-committal in character and should 
always be signed by the Principal of the school. Such a notice 
has been successfully employed under my direction in the fol- 
lowing form: 

To the Parent of 

The teacher of this child has reason to believe that he is suf- 
fering from physical defects serious enough to need attention. 
An examination by your family physician is therefore advised. 

For further details you are invited to call at the office of the 
Principal at any time you may find it convenient. 

Very Sincerely Yours, 



Principal of School. 

It is the writer's conviction that a Health Survey carried out 
in the manner suggested will result : 

First, In overcoming most of the prejudice against physical 
examinations of school children. 

Second, In educating the public in matters of Child Hygiene 
and Preventive Medicine. 

Third, In largely solving the question of expense. 



245 

Fourth, In the discovery of more than 90 per cent, of the 
urgent cases of physical defects. 

Fifth, In considerably decreasing the teacher's wear and tear. 

Sixth, In considerably increasing the children's health, hap- 
piness and efficiency. 

The significance of all of the answers obtained by use of the 
questions in the Health Survey may not at first be appreciated 
by a teacher, or other person without medical training, but 
experience and a little study will gradually make this matter 
plain. 1 



HEALTH SURVEY OF PUPILS. 
[To be made by the teacher at the beginning of the term. 
It will be noted that the questions are so asked that the nega- 
tive answers will indicate the defects discovered. ] 



Yes. 



No. 



A. General Appearance. 

1. Is the child healthy appearing? 

2. Is the color good? 

3. Is he physically well developed? 

4. Is he free from apparent deformities? 

5. Has he a good standing posture? 

6. Has he a good sitting posture? 

7. Are the shoulders even? 

8. Does the child walk normally? 

9. Are the heels of the shoes worn evenly? 

10. Is the physiological age of the child apparently 

equal to that of his chronological age 

B. Mentae Conditions. 

1. Is the child normally advanced in school? 

2 . Is he mentally alert? 

3. Does he answer ordinary questions intelligently? 

4. Does he play normally? 

1 For purposes of handy reference the teacher should make use of a few well known 
books on Child Hygiene. Among these may be mentioned: Civics and Health (Allen). 
Children in Health and Disease (Forsyth). The Physical Nature of the Child (Rowe). 
The Health Index of Children (Hoag). Medical Inspection of Schools (Cornell). Func- 
tional Nervous Disorders of Children (Guthrie). 



246 
C. Nervous Conditions. 

1 . Is the child good tempered? 

2. Is he free from abnormal emotion? 

3. Does he have good powers of muscular coordina- 

tion? 

4. Is the child free from spasmodic movements?. . . . 

5. Is he free from the nail biting habit? 

6. Does he speak without stammering? 

7. Is he free from pronounced peculiarities such as ir- 

ritability, timidity, embarrassment, cruelty, 
moroseness, fits, general misbehavior, etc.?.. 

8. Is he apparently free from bad sexual habits?. . 

9. Is he free from so-called "bladder trouble" (re- 

quests to "go out") ? 

10. Is he usually free from headache? 



Yes. 



No. 



D. Teeth. 

1 . Are the teeth clean? 

2. Are the teeth sound? 

3. Are the six-year molars in good condition? 

4. Has the child been to a dentist within six months? 

5. Are the teeth regular? 

6. Does the child use a tooth brush every day? 

7. Are the gums free from abscesses? 

8. Are the gums healthy looking? 

9. Are the upper teeth straight (not prominent)?. . . 
10. Have decayed teeth been filled? 



E. Nose and Throat. 

1. Does the child breathe with the mouth closed?. . 

2. Is he free from nasal discharge? 

3. Is he free from "nasal voice"? 

4. Has he a well developed face? 

5. Has he a well developed chin? 

6. Has he straight, even teeth? 

7. Is the child mentally alert? 

8. Is he usually free from sore throat? 

9. Is the hard palate wide (not high and narrow)? 
10. Is the hearing good? 



». 



247 



F. Ears. 



Yes. 



No. 



i. Does the child usually answer questions without 
first saying "what"? 

2. Is he fairly attentive? 

3. Is he fairly bright appearing (not stupid)? 

4. Does he have a voice with good expression (not 

expressionless) ? 

5. Does he spell fairly well? 

6. Does he read fairly well? 

7. Is he free from earache? 

8. Does he hear a watch tick as far as the average 

child? 

9. Is he free from ear discharge? 

10. Is he free from any peculiar postures which might 

indicate deafness? 

G. Eyes. 

1. Are the child's eyes straight? 

2. Is he free from chronic headache? 

3. Does he do his work without fatigue? 

4. Is he free from squinting or frowning? 

5. Is the child free from postures which might indi- 

cate eye defects, such as leaning over too near 
the desk, holding the head on one side, etc.? 

6. Are the eyes free from redness and discharge?.. . . 

7. Are the eyelids healthy-looking? 

8. Can the child read writing on the board from his 

seat? 

9. Have the eyes been tested separately with the 

Snellen Test Type? 

H. Communicable Diseases of the Skin. 



4- 



Is the head free from any signs of disease (lice, 
ringworm) ? 

Is the skin of the face, hands, wrists, forearms, 
chest free from red, somewhat circular patches 
(ringworm) ? 

Is the skin of the face, hands and forearms free 
from infected spots with crusts and pus (im- 
petigo)? ., 

Is the child free from red scratched lines and spots 
on the hands, wrists, forearms, chest and be- 
tween the fingers (itch) ? 



248 

I. Eruptive Children's Diseases. 



Yes. 



No. 



Is the child free from the following general early 
indications of contagious diseases? 

1. Flushed face 

2. Lassitude 

3. Vomiting 

4. Eruptions 

5. Congested eyes 

6. Discharging eyes 

7. Nasal discharge 

8. Persistent cough 

9. Scratching 

10. Sleepiness 

When the above outline is properly filled out the teachers 
will be surprised with the information it develops on points often 
unsuspected. As a preliminary test before the arrival of the 
School Medical Officer or Nurse, it will furnish invaluable aid. 



XXV. 

THE SCHOOL NURSE. 

By Frank Allfort, M.D., Chicago. 

The school nurse is an evolution from the visiting nurses' asso- 
ciation and this branch of nursing, while it has only been in existence 
a few years, has amply proven its usefulness and indispensability. 
It occurred to those having such matters in charge, that as public 
schools were great gathering places for the young and conse- 
quently great foci of diseases, that it would be a good plan to 
appoint nurses who should have general care of the health of the 
scholars and assist the Medical School Inspectors in their work. 
The experiment was tried and it was immediately seen that a 
great need had been supplied, and the idea has extended and 
widened until school nurses are now employed in almost all large 
cities. 

These school nurses, as a rule, were first supplied from the 
various visiting nurses' associations, but it soon became evident 
that it was unfair to place the financial burden on this association, 
and it was also felt that the school nurses were really doing mu- 
nicipal work, and that they should be paid by the municipality 
and be under its control. It therefore develops that the school 
nurses are now as a rule a portion of the health department in 
the various cities, and that their remuneration (meagre and in- 
sufficient as it usually is) is furnished by this branch of the city 
government which is the legitimate agency for its administration. 
The work might of course be carried on under a Board of Edu- 
cation as is done notably in Toronto and Colorado Springs, as 
the Board of Health in those cities did not, for certain local reasons, 
feel able to assume the responsibility. It is really a shame that 
these noble women, whose extensive, laborious and many-sided 
duties are performed with such zeal and faithfulness, and who 
accomplish so much good to mankind, should be so poorly paid 
for their services. As a rule the school nurses are under the 
direct superintendency of a head school nurse, who is, in her turn, 
under the control of the Health Department. Their work is 



250 

divided according to the various school districts, and it is, of 
course, desirable that each nurse shall have but few schools to 
care for, in order that individual necessities shall be relieved in 
the best manner possible. No nurse should have under her care 
more than 1,000 pupils, indeed, one nurse can hardly care for 
more than one school and do her work satisfactorily, and I greatly 
question whether even this is not too much labor to expect of 
any one woman. 

This opinion can perhaps be better understood, if an effort is 
made to acquire some idea of the multitudinous duties of the 
average school nurse. In the first place she shall act as first 
assistant to the medical inspector, and shall always be in at- 
tendance when he makes his visits to the school. By observation 
and consultation with the teachers, she finds sick and ailing 
children and submits them to the inspector. The carrying out 
of the inspector's orders is placed in her hands, whether this is 
done at the school, home or hospital. Many cases of skin dis- 
eases, lice, filthiness, etc., are cared for at the school by the school 
nurse, under orders from the medical inspector, and in schools 
possessing bath tanks, etc., they are operated under the super- 
vision of the school nurse. One of the principal functions of the 
school nurse is to see that the Doctor's orders are carried out. 
The doctor may diagnose and prescribe, but unless his advice is 
followed his work is useless. This important duty is performed 
by the school nurse. It must be remembered that many public 
school children are poor children, whose parents are either busy, 
negligent, impoverished, dissipated or ignorant. They probably 
have no money with which to purchase medicines, appliances, 
glasses, medical, surgical and hospital services, etc., and all these 
things the school nurse undertakes to supply by drawing upon 
the resources of charitable funds, charitable people, charitable 
hospitals and charitable doctors. These poor people are some- 
times apparently devoid of energy, and have to be cared for with 
but little confidence in their intelligence. The school nurse then 
has to secure the medicine and see that it is properly administered. 
Cleanliness, bathing, properly prepared food, sanitation, venti- 
lation, plumbing and warmth come under her supervision. She 



251 

takes children to doctor's offices, dispensaries, hospitals, etc., 
and sees that they get home again. She carries out the doctor's 
orders at home, such as giving medicines, syringing ears, using 
eye-drops, making surgical dressings, etc., she cooperates and 
works with the truant officer in keeping children in school. In 
short, through her assistance the doctor is able to prescribe or 
operate with the confident feeling that he is not working in vain, 
and that his directions will be followed as far as is humanly pos- 
sible by the already over-worked school nurse, in cooperation 
with her equally praiseworthy but over-burdened sister, the 
visiting nurse of the district. Before these commendable insti- 
tutions came into existence thousands of able operations were 
virtually thrown to the winds by poor post-operative attendance, 
and enormous stores of good medical advice nullified by neglect 
and improper living. The school and visiting nurse have become, 
then, the element which has transformed doubtful results into 
reasonably certain good results. This, of itself, is an amply 
sufficient excuse for her existence. 

The school nurse not only comes into contact with the school 
child, but also naturally and inevitably mingles with the school 
child's family, and here she performs a most important function, 
not only to the child, but to the family and to the community 
as well. By calling upon the family to look after the welfare of 
the school child, she and the district visiting nurse, if necessary, 
will endeavor to educate the family to ideas of cleanliness, honesty, 
sobriety, industry, kindness, cooking, ventilation, infant welfare, 
etc., in all of which departments of proper living there is abun- 
dant opportunity for missionary work among the thickly popu- 
lated tenement districts of our large cities. This is a department 
of charity which, unfortunately, will never be overdone, and the 
extent of its usefulness is only outlined by the amount of money 
that is eligible for the purpose. I believe there is no charity 
which furnishes such extensive results for the money subscribed 
as the visiting and school nurse, and no object for which people 
may so safely and blindly contribute financial support as the 
one under consideration; every dollar given helps to make indi- 
viduals and communities better, healthier and happier. 



252 

The experiment is being employed in small towns of employing 
school nurses to act as medical inspectors, and so far the plan 
has given great satisfaction wherever it has been tried. Of 
course, in sizable cities, the function of the medical inspector 
should not be supplanted, but in small communities where there 
are only a few schools and only a very few doctors (who are, 
perhaps, jealous of each other) , there seems to be no good reason 
why a school nurse, who devoted her entire time to the work, 
should not be able to render very satisfactory service. Of course, 
she cannot diagnose disease as well as a medical man, and this is 
really not necessary, as her function is not to treat the children 
medically or surgically, but to ascertain the existence of disease 
and defects and then refer such abnormal children to a doctor, 
after which the nurse can, if necessary, assist the doctor in the 
carrying out of his advice. The school nurse under these cir- 
cumstances should never recommend any particular doctor in 
her small community; she is the servant of the entire town and is 
being paid by its public funds, to which all the doctors contrib- 
ute. She should, therefore, treat all the medical men alike, as 
it is only by perfect fairness in such matters that the plan can 
possess any prospect of a permanent existence. Such school 
nurses should understand that they are not only employed to 
inspect the defects and diseases of the children and then advise 
the parents to take them to a doctor for treatment, but that 
they are also employed to do what seems necessary, to see that 
the doctor's orders are carried out, both in school and at home, 
and to do whatever home visiting is indicated among the poor 
and needy, and to do whatever she can for their condition and 
welfare. It will be seen that a school nurse who is expected to 
do such responsible and varied work must be a woman of age, 
tact and experience, and communities should see that they are 
well paid for their labors. > 

Another function which has been suggested for the school 
nurses in large cities, is to examine children for eye, ear, nose 
and throat diseases, instead of having such examinations made 
by teachers or doctors. It is the consensus of intelligent opinion 
that boards of health should have authority over such physical 



253 

conditions of children that menace the public health, or which 
involve acute illness, while boards of education shall supervise 
the inspection of children for physical defects, or diseases of a 
chronic nature, which do not menace the public health. With 
this idea in view, abnormal conditions of the eye, ear, nose and 
throat would be inspected under the supervision of boards of 
education, and is done by either teachers or doctors. Doctors 
are expensive, not reliable as to time, and usually produce pro- 
fessional jealousy and discord. Such examinations can best be 
accomplished by teachers under the system which I proposed 
years ago. By this method, the teacher, by asking nine questions, 
ascertains the existence of about 95 per cent, of all serious de- 
fects and diseases of the eye, ear, nose and throat. No medical 
education is necessary for the test, which does not consume more 
than 5 minutes for each student. In case a defect or disease is 
found the child is sent to a doctor of the parents' choosing. Each 
teacher has about forty pupils in her room and she could examine 
them all in a day. A day in each early Fall should be dedicated 
to this work, and by such subdivision of labor every school child 
in any city could be easily inspected in one day. The cost is 
practically nothing, and the teachers will all be abundantly 
repaid for this apparently extra work when their labors become 
ultimately lightened by the transformation of stupid children 
into bright children, when their defects or diseases are relieved 
by glasses, treatment, or operation. 

It has been suggested that this work be done by a few school 
nurses who should go from school to school and inspect the 
scholars. There can be no possible objection to this plan, pro- 
vided the board has money to spend for its accomplishment. 
In a city like Chicago, for instance, it would cost several thousand 
dollars if school nurses were employed to do the work, while it 
could be done sufficiently well by the teachers, for the mere cost 
of the printed matter. Teachers are perfectly competent to 
make the tests, and it is folly for them to claim it to be unjustified 
extra work. It is not extra work, it is economy of work. No 
individual's work in a school room will be ameliorated as much 
as the teacher's. This is a fact, which she ought to understand, 
acknowledge and act upon. 



254 

It will thus be seen that the duties of a school nurse are varied 
and arduous, and that although one day inevitably merges into 
another day, her work is never finished. School nurses should 
be mature in years, ripe in experience and possess great tact and 
patience and be in love with the work. If endowed with these 
qualities, she will find her profession to be one from which she 
derives the greatest satisfaction, but if not so endowed, she 
would better choose some other avenue of work. 

7 W. Madison Street. 



XXVI. 
OPEN-AIR SCHOOLS. 

By Thomas Wray Grayson, A.M., M.D., Pittsburgh. 

To my mind, no conference on the "Conservation of School 
Children" would be complete without a consideration of open-air 
or fresh-air schools, for such schools will literally enable children 
"to have life and to have it more abundantly." 

An open-air school is one in which the pupils are kept entirely 
in the open air, a curtained pavilion or a shed with many win- 
dows and doors being used to give to the children the protection 
necessary from rain, wind and sun, but wide open to the outdoor 
air on at least one or two sides even in the stormiest weather. 

In 1904 the first "open-air recovery school" was started in 
Germany and now we have many such scattered all over Ger- 
many, France and England. In fact, many municipalities 
have taken up the movement with enthusiasm, and open-air 
schools now are as much the care of a city's government as public 
playgrounds, public baths, etc. 

Five years ago the first outdoor school was established in this 
country in Providence, R. I. Boston, New York and Chicago 
followed soon after. There are now fifty or more scattered over 
the United States and they are multiplying rapidly; this in 
spite of the fact that the methods of municipal and educational 
management in the country make the beginning of any new work 
like this much more difficult here than in the countries named. 

To correct a very common misapprehension in regard to open- 
air schools, let it be understood that they are not exclusively for 
tubercular pupils. While this movement — especially in America 
— has been initiated by anti-tuberculosis societies with the idea 
that this is one of the best ways to fight the "white plague," 
people soon learn that the little sufferers from anemia, chorea 
and many other chronic or sub-acute diseases can be benefitted 
almost as much as the tubercular; and, furthermore, schooling 
in the open air will keep well children healthy, will improve their 



256 

mentality and in every way be much better for them than the 
closed school-room. 

About one or two per cent, of the children in our public schools 
are seriously enough affected by tuberculosis or are in some other 
way definitely enough diseased to warrant their being treated 
in a sanatorium. In nearly every case a fresh-air sanatorium is 
what they need, and the work of fresh-air schools shows that the 
education of these children can go on as usual while their health 
is being attended to. In these children the open-air school would 
emphasize the hospital or sanatorium part of the proposition, and 
might be described as a "Sanatorium School." It would, of 
course, be the most expensive kind of an open-air school. Care- 
fully recorded observations of living children and autopsy reports 
show that tuberculosis is much more widely spread than was 
formerly thought. German observers who have made many 
post-mortem examinations assert that the majority of children 
thus examined show signs of tuberculosis, and American physi- 
cians who have examined many school children have found twenty 
per cent, or more affected. Considering that this is but one of 
the conditions in which open-air schooling would be a great 
benefit, the great need of such schools can be seen, although of 
course not all such children need to be in a sanatorium school. 

In the next place, many children are not definitely diseased, 
but are not strong. They are underweight, catch cold readily, 
are easily tired out, are over-excitable, etc. In these, the results 
of the fresh-air school are just as brilliant as in the previous class. 
Weights come up to the normal, hemoglobin increases and pulse 
rate and temperature become what they should be, and in every 
way the children approach the standard. The resisting power of 
the pupils is so improved that they are not subject to "colds" and 
other such contagious diseases. Attendance at school conse- 
quently improves, and — more wonderfully than all — mentality 
improves with this fresh-air life, so that the pupils are able to 
maintain their grade with much less study than in the closed 
school-room. More time can be spent in supervised and unsuper- 
vised play, and night work can be dispensed with. 

This second class of children would include something like five 



257 

per cent, of our school children, but why should it not include 
all of the children who are not definitely diseased, or come under 
the care of what I have called the Sanatorium School ? If experi- 
ments in hundreds of cities have shown that children who are not 
strong are improved physically and mentally in these open-air 
schools, must we not conclude that with a little extra provision 
for the comfort through our northern winters, such schools will 
keep healthy children strong and enable them to do their school 
work more thoroughly and in better time? 

If I had my way, there would be no third division to the subject, 
for all our schools would be conducted in the open air, or at least 
be "Open Window" rooms; but until parents and educators will 
learn how desirable these schools are, we will continue to have 
closed school-rooms, and for these I wish to plead for better ventil- 
ation than we now have. 

In open-air schools, warm clothing — often especially made of 
blanketing — is provided, and sitting-out bags, soap stones, felt 
boots, mittens, blankets, etc., are used when needed. In some 
of these schools the children come for breakfast and stay all day, 
having a warm luncheon and supper provided at the school. In 
others, they spend the same time as in the public schools, except 
that the noon-day meal is provided at the school. Cots or steamer 
chairs are used by those pupils who are found to require an after- 
noon nap. It is remarked that the children bear the cold much 
better than adults. When visitors are uncomfortable and teachers 
and nurses are hardly able to keep warm, the children will be 
comfortable and happy, with rosy cheeks and warm hands. 

The medical results in these schools are surprisingly good. 
While we can roughly estimate the child's reaction to cold by the 
color of the cheeks, a surer method — and the one usually adopted 
in these schools — is to examine a drop of blood and estimate its 
hemoglobin. In this way, the physicians can see that the oxygen- 
carrying power of the blood steadily improves with the life in the 
fresh air. It is also gratifying to notice how the weights come 
up. A gain of a pound a week is not unusual, but it is a rare 
thing that the children do not show a more rapid gain than is 
seen in the normal growing child. One reason for this is of course 



2 5 8 

that the life in the fresh air almost invariably improves the ap- 
petite. After one month or two of this life children will eat twice 
as well as they did before, and the pale, sickly child which had to 
be coaxed to eat, will be glad to eat almost any food served. 

It is surprising what open-air schools will do for nervous chil- 
dren. These little ones are poorly fitted for the battle for life. 
There may be a tubercular taint at the bottom of the nervousness, 
but for practical purposes, these pupils are merely nervous. 
The outdoor life steadies the nerves probably because it builds 
up the physical condition. Such an excitable child may be in- 
jured by the artificial life and the high pressure of the closed school- 
room, so that the mother may be alarmed by the condition of 
her child at the end of the school day, and may object to the 
study at night, even pleading for shorter school hours or keeping 
the child out of school frequently. The open-air school has a 
tendency to change all this. As the physical condition improves, 
the nerves become steadier and open-air life makes the required 
amount of study less of a task and a shorter one. Furthermore, 
the psychic effect on these children is for good. If the teacher is 
at all tactful, the child learns that the slight discomfort on cold, 
stormy days is easily borne when the proper frame of mind is 
cultivated, and thus the "psychic hardening" which the children 
undergo, is a valuable part of their education. 

While common colds are prevalent among children in our 
ordinary schools, they are rather unusual among the pupils of 
fresh-air schools, thus adding another link to the chain of evidence 
we have that many diseases of the respiratory tract are caused by 
impure, overheated air. The ordinary contagious diseases of 
childhood, too, are much less prevalent among these pupils. In 
such a school in Pittsburgh the past winter the first such disease 
to make its appearance was tonsilitis, one case, but it was found 
that this child's mother had kept her home for the last two weeks 
because she thought the weather was too cold! Another pupil 
developed chicken-pox from an undiagnosed case in an older sister, 
but no other case developed in the school. In fact, colds were 
absent and improvement took place in sickly children in direct 
proportion to their school attendance, and the mothers who 



259 

kept their children out of school the coldest days were the few 
who could not be made to see this. 

Educationally, these schools are a great success. In most of 
them the attendance has been decidedly better than in the ordi- 
nary closed school, although they take the sickly, pampered 
children who are often allowed to stay home when they wish. 
Most of the children learn to appreciate what is being done for 
them, and are anxious to get all the benefit possible. In fact, 
they have been known to object to a vacation. 

The fresh air and the improved vitality in nearly every case 
bring about an improvement in the child's mentality, so that less 
time is taken up with regular school work, but the children are 
easily kept up to grade. In many cases, children who have been 
handicapped by ill health for years and have been struggling along 
in the ordinary closed school-room, have quickly brightened up 
in the open-air schools and have become normal, interested and 
interesting pupils, much to the surprise of their teachers. 

In fact, fresh-air schools have been thoroughly tried and edu- 
cators have come to the conclusion that the proposition is not a 
medical one, but one of practical teaching. While such a school 
may call for added resourcefulness on the part of the teacher in 
managing an ungraded school in all kinds of weather, it makes the 
actual teaching much easier, for it increases the child's ability 
to learn by making him more capable of clear thought and awaken- 
ing his natural desire for knowledge. It has often been noticed 
by teachers and parents that these children become more orderly 
and cleaner than in the ordinary school. 

Thus we see that the pupils in such schools are benefitted in 
body and mind. They also take the lesson of hygienic living 
back to their homes. If these schools are generally adopted, a 
great good will be done to pupils, teachers and families, and much 
money will be saved in doctors', nurses' and fuel bills. Many 
school buildings can then be of simpler and cheaper construction. 

These schools have not been given up, so far as I know, in any 
city that has adopted them. The movement is becoming a recog- 
nized part of the public school system. In fact, the time is fast 
coming when our public schools will be maintaining open-air 



260 

schools for sickly children, schools for backward children, schools 
for truants, vocational schools, night schools and other special 
schools. 

This paper may be concluded with the following recommenda- 
tions : 

First, that every public school of any size should have in 
connection with it a room where children who are not strong can 
have their health built up with proper medical care and nursing 
(observation, nourishing food, warm clothing and rest periods) 
while the education is still being carried on. 

Second, that every public school should have many open-air 
or fresh-air rooms, provided with an unusually large window space, 
kept open as much as possible, thus giving children who are 
underweight, anemic or dull mentally a chance to get the good 
effects of fresh air, which the ordinary school does not supply. 

Third, that less heat be forced into our school-rooms, and more 
of the naturally moistened air, for which we have found no ade- 
quate substitute, be admitted. 



XXVII. 
MEDICAL INSPECTION OF SCHOOLS. 1 

By Edward W. Goodenough, M.D., Waterbury, Conn., Chairman of Committee on 
Medical Inspection of Schools, Connecticut State Medical Society. 

To prevent disease — this, as I understand it, is the purpose of 
this organization. You are the directors of health and sanitation. 
Isolation and disinfection following disease still form a large part 
of your task. If we can kill a snake or remove the poisonous 
glands before he strikes, he is harmless. Absolute disinfection 
without destruction, as by fire, is certainly difficult if not impos- 
sible. How we search for means which will increase the average 
individual resistance! In medical inspection of schools, properly 
carried out, we can give antitoxin for diseases in general without 
the use of a hypodermic needle. How far is state, city or town 
government justified in expending money for this purpose? 

System is the watchword now in all business. Perpetual 
motion — the fountain of youth — impossible! yes — but approach- 
able surely. We laugh at the philosopher's stone and trans- 
formation of baser metals into gold. Has not standard oil made 
gold out of coal oil, and how about iron ore under the influence of 
Pittsburgh and the steel trust? Economy, system and a little 
water for washing — presto, change, and the impossible is accom- 
plished. 

We burn sulphur and we liberate formaldehyde gas. We even 
use steam or fire. A typhoid carrier, a diphtheria culture breeder, 
a few chicken-pox cases with continued high temperature and 
days in bed — our protection goes to the winds. 

Life with her anti-vaccination and anti-vivisection does stir 
us up some and occasionally finds a hole in our armor, but that is 
the joke of it. 

Dr. Chapin, of Providence, finds the weak places and then goes 
ahead with all his might to fill them up. Professor Fisher writes 
about conservation of national vitality. A national board of 
health is coming, but while we wait, Connecticut is fortunate in 
her state health officials and their efficient secretary. He says 

1 Read before the Health Officers of Connecticut, April 3, 1912. 



262 

medical inspection of schools is a part of the real thing, and he 
is right. This means education in hygiene; in personal cleanli- 
ness. The importance of healthy growth is recognized by competent, 
well paid medical supervision. Here it is, the fountain of health 
in youth surely, if not the fountain of youth. We prevent disease 
by instilling into children through every grammar grade the 
benefit of fresh, not overheated air, with a clear nose to breathe 
it through and a clean mouth to masticate their food with, a 
mouth and naso-pharynx which shall not breed disease germs for 
their own injury or that of their schoolmates. 

We are all creatures of habit. A child is more complex than a 
plant, yet child culture means the application of Burbank methods 
to the different species of the genus homo. Our schools are the 
culture beds in which grows our citizenship of wheat and tares. 
The highest work of plant cultivators is not the freak work. 
Because of the knowledge obtained by the cultivators of plants 
we have larger and more perfect grains of wheat, more perfect 
apples and pears and peaches. We know how to get maples and 
oaks and pines of the best character. We also know how to 
make the best use of waste soil, how to make the desert bloom 
as the rose. 

We live in a republic. The children in our schools are our 
future citizens. If a majority of the children in the schools are 
properly developed, physically and mentally, we have done our 
part toward the development of a healthy, normal and therefore 
a generally happy citizenship. Each individual character is a 
combination developed out of good and bad habits. Nor do I 
refer to morality alone. Our bodies are a combination of good and 
bad habits of physical development, our minds are combinations 
of good and bad mental development. The earlier we begin, the 
easier it is to develop good habits. 

To get the best fruit from a tree or vine, pruning is often neces- 
sary. In this way we remove the overgrowth in leaf and stem, 
and allow the fruit a larger proportion of the plant nutrition. 
In children an overgrowth of adenoid tissue in the nose or throat 
lessens the amount of oxygen which enters the lungs and the 
amount of blood which nourishes the brain. If not too long 



263 

delayed, the removal of this overgrowth will allow both lungs 
and brain their normal food supply. If 10 per cent, of the children 
of school age require such operations, we surely should see that 
parents are informed of the fact. The younger a child is, the 
more easily it is influenced. Every child has ideals and it is one 
of the functions of school life to elevate and develop these ideals. 

Every physician who has much to do with children should 
become an optimist. We see children who are apparently physi- 
cally hopeless. Their nutrition is bad, they belong to that class 
which "the survival of the fittest" would apparently wipe off 
from the face of the earth. With proper care these children 
develop rapidly and often become leaders. It is because of this 
knowledge that we are constantly working for improved physical 
conditions in the public schools. The open-air school is an out- 
growth of this effort. In the school at Bradford, England, where 
school inspection was early developed, out of sixty children only 
two had pulmonary tuberculosis. These, of course, had neither 
cough nor expectoration; tuberculous children with cough and 
expectoration must attend open-air sanatoria like the one at 
Wallingford. This distinction should be clearly made. 

Children with tuberculous glands or tuberculous bone disease 
who are not a source of danger to others are subjects for open- 
air schools. With them, anemic children and those with de- 
fective nutrition, are specially benefitted. Such open-air schools 
can be established in our own yards and such children play with 
our children with impunity. Constantly kept in a closed room, 
however, these physical defectives may not only go from bad to 
worse, but become a menace for this reason to other children in 
such closed rooms. We have already built in Waterbury an open- 
air school which I hope will soon be used. 

During the two years of my service as medical inspector 
of the Waterbury schools I reported to parents 1250 cases 
of adenoids and enlarged tonsils. This is about 10 per cent, 
of the public school children inspected and included only 
those cases which showed symptoms requiring operative relief. 
In 450 cases the obstruction was removed. 200 children ob- 
tained glasses for eye defects and a number of others were given 



264 

special advice and treatment by an oculist. All cases of scabies, 
favus and ringworm were eliminated from school. All the 
children in the grammar schools above the first grade were ex- 
amined by the Waterbury Dental Association for tooth defects, 
and where such defects were present a chart of the mouth condition 
was sent to the parent. The use of solutions of lysol or liquor 
creasol comp. were recommended for head washing and there 
were less than one-third of the number of pediculosis cases found 
at the end of my term of service than were found at early exami- 
nations. In the worst district, out of some 700 children, the 
percentage of these cases were reduced from 50 to 8 per cent. 
For this result the energy of the principals, assisted by the teachers, 
was largely responsible. 

I read that Hartford and New Haven are to have a clean-up 
day. One of our principals has talked so much to her children 
about sleeping with open windows that they are much ashamed if 
necessary to report that their sleeping rooms are not nightly aired. 
This same principal asked the children to have their big brothers 
or fathers clean up the cellars and backyards, and in this way 
much was accomplished for the district. At the last meeting 
of the Board of Health the persistent overheating of a twenty- 
seven room building was reported by the Medical Inspector. 
The month before an effort was made to remedy a poorly lighted 
first-grade room in another building. You all know how difficult 
it is to get even an approximate report of cases of measles, whoop- 
ing cough and chicken-pox or as the Borough of Naugatuck shows 
even the cases of small-pox. Through the Medical School in- 
spectors and the nurses, a much closer watch is kept on these 
cases. With a thorough examination and record of each first- 
grade child and fifth-grade child, we have data which in time can 
be very valuable. The Medical Supervisor of the future will be 
an educator. The young children easily influenced will learn 
by observation the value of fresh air, not overheated, the de- 
sirability of cleanliness, the possibility of infection and contagion 
and therefore the value of isolation. They will learn what foods 
they should eat, and, among the poorer classes, what foods give 
the most nourishment at the least expense. All will not follow 



265 

the advice given or the example set, but enough will do so to 
materially inprove our citizenship. 

I have not discussed the mental defectives although lack of 
room at Lakeville makes this a serious problem. The time will 
soon come when every child in this state will be given every 
opportunity the public school can give for education in physical 
as well as mental health. 

Let me quote from Hogarth his conception of what medical 
inspection means. 

i . The state requires a physical census of the children for the discovery of 
unrecognized defects, partly with a view to the improvement of the national 
physique, and partly with a view to the preparation of all children for school 
life. It is also a national duty to arrange for the classification of children 
according to their mental capacities, and to adopt the educational system 
to the requirements of the several groups of children, in order to diminish 
the present economic wastage of misdirected educational efforts. 

2. It is the duty of local authorities to protect the individual against 
communicable disease in school, to supervise school buildings, and to secure 
healthy surroundings for the school child. 

3. Owing to ignorance, neglect, or apathy on the part of parents, it becomes 
a requirement of the merest humanity to bring medical aid and special educa- 
tional methods within reach of the individual child. 

These aims and ideals can be attained only by the introduction of a system 
of routine inspection of the children by medical men interested, not only in 
public health, but also in education. 

These paragraphs seem fairly well to cover the subject if we 
would revise the first paragraph by saying "the State of Con- 
necticut should require" etc. 

For two years, 1910-1911, 1 was Medical Inspector of the schools 
of Waterbury. As an appointee of the Board of Health I visited 
the parochial schools as well as the public schools. I also super- 
vised schools in the outside districts which were still under control 
of District Committees. During thirteen school months I had 
the assistance of a school nurse. Although an appointee of the 
Board of Health, I had the unqualified support of the school 
department, superintendent, principals and teachers. My work 
was that of a medical supervisor really. Seeing the children only 
once a month it was necessary for the teachers to emphasize 
each day the lessons which I tried to give each month in cleanli- 



266 

ness and neatness. I found that I could inspect, very super- 
ficially, an average of about five thousand children a month. 
The nurse who assisted me spent most of her time among the 
families in the different districts in order to see that recommen- 
dations for treatment were carried out. This year we have two 
nurses who are paid $80 a school month each and two doctors 
who are paid $60 a school month each. Depending upon the 
districts, a nurse should spend from forty-five to fifty -five hours 
a week in school work. Under the supervision of a physician 
much of the detail work which I did can be done well enough by 
a nurse. There certainly should be a nurse or doctor to do this 
detail work for each two thousand children or a fraction of two 
thousand and in all towns of five thousand inhabitants there 
should be a physician appointed to have medical supervision of 
the school children. Under his direction should the detail work 
be done. 

The new record cards of our school department are planned 
in the belief that a physical examination should be made of every 
child on entering school and that another examination should be 
made at the end of primary work or at least at some time before 
the end of the grammar school. This could be done by the 
supervisor assisted by some of the younger physicians who could 
give their time to this work during September and October of 
each year. Where parents prefer to pay their own physician for 
such examination, the cards can easily be filled out by such 
physician. With two such examinations, five years apart, we 
could get a much more intelligent idea of the healthfulness of 
certain school districts or even of certain school buildings. It 
was suggested to me by a prominent health official that friction 
between the health and educational board could be obviated if 
the doctors and nurses were appointed by a joint committee of the 
health and educational boards. Certain it is that medical in- 
spection of schools should bring school department and health 
department in closer harmony. 

I received my early education in a small country school in this 
state. These schools need some sort of medical supervision. 
With a medical supervisor of several towns it should not be 



267 

very difficult at least to have a yearly visit from such a physician 
and each town could afford a school nurse for a portion or all of 
the school year. 

Public schools are socialistic. We have compulsory education 
at certain ages. Society thus seeks to protect itself against 
ignorance. The health board of this state with compulsory 
quarantine and compulsory vaccination is decidedly socialistic 
in its protection of the citizens against ignorance or abuse of 
health laws. If sanitary laws are to be enforced for the public 
good, why not make education in practical sanitation and hygiene 
a part of our educational system. In another generation our 
citizens will show that it was worth while. 



XXVIII. 
THE DESIRABILITY OF TEACHING PREVENTIVE MEDI- 
CINE IN THE HIGHER INSTITUTIONS OF 
LEARNING. 

By Henry Bixby Hemenway, A.M., M.D., Evanston, 111. 

Education has two objects — training of the mind, and the 
acquiring of information. In the lower schools the first of these 
objects is by far the most important, but the higher we go in the 
educational system training becomes relatively of less and less 
importance, and the information element becomes predominant. 

Even the information factor may be divided, according to the 
object sought. The scientist learns German or French, not for 
the language per se, but as a key with which to unlock the doors 
to storehouses filled with special facts. Again, these special 
facts may be classified according as they may be used by the 
student in later life as a means of support, or as simply influencing 
his life as a member of society, or for the pleasure of knowing, 
which is the highest aim in true science. 

In arranging a course of instruction, therefore, choice of sub- 
jects must be governed by the relative position of the institution 
in the educational system, and the character of the students, as 
well as their probable future lives. In considering the needs 
of the students, preference must of necessity be generally given 
to the character and aims of the majority, rather than to the 
exceptional man. 

By the expression "higher institutions of learning" we under- 
stand that reference is made to that general class of schools 
familiarly called colleges of liberal arts, and to other colleges, 
academies, and seminaries, approximating in character thereto. 
The reasoning hereafter given in this article applies to technical 
institutions only in a very general way, except to those known 
as normal schools. 

The expression "preventive medicine" is of recent origin. 
Its scope and importance is indicated by the old saw, "An ounce 
of prevention is worth a pound of cure." It is far easier to 



269 

prevent a fire than it is to put it out after it has started, and if 
put out it may have wrecked and destroyed invaluable objects. 
From a biologic standpoint the most perfect life is health. Dis- 
ease is a condition in which the life lacks its highest standard. 
Disease does not enter the body unaided, but it must be assisted 
by bacteria, unhygienic environment, and the personal sins of 
the victim. It was formerly supposed that hygiene — the preser- 
vation of health — was chiefly an individual concern. To-day 
it is recognized that the same conditions which produce disease 
in one person affect others in the neighborhood, and that one 
case of sickness may be a serious danger to a large city. It is 
impossible for one person to protect himself efficiently in a city 
infested, for example, with the plague. The interests of the 
citizens are common, and protection can best be secured by con- 
certed efforts. In addition to the personal hygiene which has 
so long been recognized as a preventive power, we have more 
recently magnified the importance of organized efforts by the 
entire community. To-day this is the major part of preventive 
medicine. 

Efficient organization necessitates, first, recognition of the 
need for organization. Second, competent workers in the field. 
Third, necessary support of the workers as individuals, and of 
the work conducted. 

A recognition of the need for organization can come only when 
there is a general diffusion of basic principles in health work. 
So long as malaria was supposed to be an aerial miasm, and per- 
haps influenced in its spread by conditions of cold, or dampness, 
it would have been manifestly impossible to institute efficient 
antimalarial measures. When typhoid was supposed to be only 
waterborne, the need could not be recognized for food inspection 
and safeguards. Note the destructiveness of the fly at Chick - 
amauga, in 1898. Unfortunately to-day, though there has 
been a great increase in the amount which a few know in this 
general field, the mass of citizens are still in midnight darkness. 
Having always been in that darkness they do not realize that 
there is any possibility of having more general light. How shall 
they be enlightened? 



270 

It necessarily follows that if the people as a whole are in dark- 
ness, and do not know the elemental facts of the present science 
of preventive medicine, they will be unwilling to furnish the 
supply of money needed for the work and for the support of the 
workers. Further, because the mass is ignorant of the need for 
the work, and also because they are not willing to pay the workers, 
those who should be preparing themselves for positions of re- 
sponsibility in the service will not consider such a possibility. 
They can not. 

Laws can neither be well made nor enforced unless the persons 
responsible are well informed upon the subject. In a republic 
all citizens have a responsibility in this regard, and it therefore 
becomes the duty of all persons to become posted upon the 
principles of preventive medicine. To thus become informed, 
they must have instruction, and the instruction must be in pro- 
portion to their capacity. It has been found that such education 
in the grade schools not only becomes an active leaven in the body 
politic, but that it also serves well as a means of teaching the 
scholar to think. But, in order that the teacher may properly 
give such instruction it is necessary that she be educated to a 
higher degree upon the subject. This presupposes that she shall 
have had instruction in her higher school training. She must 
be able by precept and example to lead the children into the light, 
and to inspire them to seek further advancement. 

Take, for example, the subject of malaria. At Trinidad, Sir 
Rupert Boyce saw excellent studies of the life of the mosquito 
in the note-book of a little girl in the grade schools. Such a study 
teaches the child observation, as few subjects can. It trains 
both brain and muscular control, with an incentive which is lack- 
ing in mere training for training's sake. It serves therefore every 
essential of a true education. 

In higher institutions the student may be taught how to study 
and analyze facts and statistics, the work of the laboratory, and 
research into the literature. These are matters of training, 
independent of the subject studied, but they are given additional 
interest to the student by virtue of the e very-day application of 
the facts developed. Preventive medicine is therefore an ideal 



271 

subject for advanced work in the arts and sciences, in schools 
of liberal learning. 

Graduates from the higher institutions of learning are naturally 
looked to for guidance in forming public opinion. At present 
these graduates depend upon the uncertain and often erroneous 
information derived from the secular press. We can not expect 
that we may obtain wise laws relative to vaccination, for example, 
so long as the makers of public opinion are so profoundly ignorant 
as at present. There are few subjects so vital for the citizens as 
the preservation of public health. In selecting a curriculum, 
therefore, this subject should demand preference, especially since 
it is well fitted for the proper training of mental operations. 

The literary colleges are far better fitted for giving the general, 
or fundamental ideas as to public health conservation than are* 
any technical schools. There are, for example, certain principles 
of administrative law in the administration of health depart- 
ments which may be easily given in connection with the courses 
in literary colleges, whereas, in a technical school the same in- 
struction would necessitate the use of more time, and frequently 
it would require another instructor. 

It is hoped and expected that before long all medical students 
must take one or more years in the literary colleges before entering 
the technical schools. The education given in a literary college 
should prepare the medical student to omit preliminaries, and 
devote his time spent in the study of preventive medicine directty 
to the purely technical portion of the subject. 

No matter how thoroughly fitted the public health adminis- 
trator may be, even if he may secure the pa sage laws which are 
satisfactory, the enforcement of such laws will be difficult or 
impossible until the people as a whole are educated up to a full 
appreciation of the facts. For example: Rabies was formerly 
supposed to be dependent upon hot weather. A law requiring 
dogs to be muzzled through an entire winter would be opposed 
by many ignorant, but well meaning people to-day. Enforce- 
ment of the law would require extra supervision, and would often 
necessitate expensive litigation, ending possibly in the repeal of 
the law, and the crippling of administrative efficiency. 



272 

So far we have spoken especially of a general education in 
preventive medicine. Up to the present time such instruction 
has not been usually given, and practically there is no possibility 
for such training unless the literary colleges wake up to the neces- 
sity, and make suitable provision in their curricula. It must be 
remembered that the technical education of professional workers 
in the field is to-day given in non-medical schools. In other 
words, there is fully as much, if not more, of the special education 
required which naturally falls within the schedules of schools 
of engineering, for example, as in medical schools. On the con- 
trary, there is more in the medical school training which is foreign 
to preventive medicine. The result is that many of our foremost 
sanitarians are not graduates in medicine. In medical practice 
there is little need for knowledge of general zoology, geology, 
mechanics, mathematics, law, and higher chemistry, all of which 
are of great importance in preventive medicine. More than 
three-quarters of the medical course is only of remote application 
in preventive medicine. Medical men are a necessity in the work, 
and a medical man with the other education also is the ideal 
health official, but it appears that for some time at least very 
much of the technical training for health officials must be in non- 
medical schools. 

At the University of Illinois, during the past school year, a 
course of free public lectures upon preventive medicine was given. 
The lecturers were prominent special workers. The course was 
freely advertised. In spite of this, the attendance was far from 
satisfactory. Prof. Milton J. Rosenau, of Harvard, gave the 
Harris Lectures at Northwestern University this year. His sub- 
ject was intensely practical. A class of young ladies from the 
Normal School at Normal Park came twenty-five miles to attend 
the course. Still the attendance of Northwestern students was 
far from what it should have been. It is not sufficient that such 
courses be given. Since the subject is one of vital interest to the 
community as a whole, attendance on at least a portion of this 
instruction should be compulsory. 

We would suggest that as a start one competent instructor be 
engaged. He might personally give lectures upon the general 



2 73 

subject, and these lectures all Freshmen should be required to 
attend. He should also conduct class work, which might be 
elective. Seminar work should also be provided. Such an in- 
structor might, through conversation with the professors in other 
departments, see to it that in the other courses emphasis be 
placed upon public health subjects. For example, the professor 
of zoology might well devote special attention to the classifica- 
tion, and life habits of flies, mosquitoes, ticks, and other insect 
carriers of disease, as well as the rat, ground squirrel, guinea pig, 
and other animals which are to-day receiving the attention of 
public health workers, either as dangers, or as subjects of ex- 
perimentation. So, too, the department of political science 
should bring clearly before its students the special points in 
administration and legislation which have bearing upon this 
work. The botanical department may, and should, give instruc- 
tion in the science of heredity, and in this even the chemical 
department may give assistance. Such instruction in other 
regular courses would not in the least disturb those courses, and 
they would aid not only in the practical education, but also by 
attracting attention to this field. These other professors, special- 
ists in their fields, might also give a special hour occasionally to 
the class conducted by the professor of preventive medicine. 
Unless there be a professor, or instructor, of preventive medicine 
to call the attention of other professors to the special bearing of 
their departments upon public health, it is not likely that they 
will think of making prominent these important items which 
naturally fall within their particular fields. 

The objections to such courses are first, a lack of appropriation. 
This lack is per se evidence of the need for such education. Funds 
are forthcoming for all causes whose public value is appreciated. 
It is to-day relatively difficult to get a hearing before the people 
upon subjects connected with public health. There is beginning 
to be a change in this regard. We may reasonably expect that 
ere long endowments will be generally made for the instruction. 
At present such endowments as are made are for the purpose of 
investigation. The knowledge of the few investigators and 



274 

workers has already far surpassed administration, and general 
appreciation. 

The second objection is that the interest of the students is 
very problematical. This is true, and it can be demonstrated only 
by trial. The success of the trial will be largely dependent upon 
the personality and method of the instructors. 

It is objected further that there is as yet no demand for such 
courses. Certainly there is not. The demand cannot precede 
the appreciation of the need. Because the people do not know 
that they are in darkness which stunts their own individual 
growth, they do not call for light. Further, to a very great 
degree students take without question the courses offered and 
do not demand something not down on the published schedule. 

Again, there are some who oppose this innovation because 
they do not know how to arrange for credits in this work. This 
is purely an administrative question. Its answer must be gov- 
erned largely by the courses offered. To urge this as an objection 
is a confession of administrative laziness or inefficiency. 

Finally, it has been objected that no suitable text-books are 
available. This is hardly true. Harrington's "Hygiene, " Egbert's 
"Hygiene and Sanitation," or the "Rural Hygiene" of either Ogden 
or Brewer might serve very well for such use, supplemented with 
other instruction which a competent instructor might give. It 
would be a practical impossibility to cover all of the subject in 
one book at present. If the work is done by recitation, the 
students might well be expected to do general reading from many 
sources in the college library. Such reading should include 
certain portions of constitutional and administrative law, with 
cases, works on meteorology, climatology, and zoology, for ex- 
ample. The lack of text-books is not therefore a valid objection. 
If it shall later appear that there is such a deficiency it will un- 
questionably be filled. 



XXIX. 

MANAGEMENT, MAINTENANCE AND EFFICIENCY OF 
THE SCHOOL FOR CRIPPLES IN CLEVELAND. 

By J. E. Tuckerman, A.B., M.D., Cleveland. 

In the State of Ohio we have public institutions for the blind 
maintained by the state. There is a school for the deaf entirely 
under the control and maintenance of the public school system 
in Cleveland. There is, however, no fully controlled public insti- 
tution for the care of crippled children who cannot get to and 
from school. It remained for private benevolence to start such 
an institution. 

The Sunbeam School for Crippled Children was originally 
founded by an organization called the Sunbeam Circle and was 
incorporated in June 18, 1902. Its membership was limited to 
thirty active members paying dues of $5.00. Provision was 
made for honorary members having dues of $2.00. There are raj! 
present about 148 contributing members who, while not active. 
in the management, contribute to the support of the enterprise. 
Originally the efforts of the Sunbeam Circle were confined to the 
buying of braces for needy children and to the maintenance of a 
day nursery or kindergarten under the charge of Miss Amy Noak. 
In 19 10, part of its activities were assumed by the Cleveland 
Board of Education under Director Charles Orr. The present 
arrangement therefore is a cooperation of private charity with 
the public school system. 

The school is housed in a portable addition or separate building 
of one story construction on the grounds of the Wilson School 
on East 55th St. There are three class-rooms, a small surgery, 
and a kitchen. The children are called for by omnibuses and 
thus taken to and from school. The sessions last from nine in 
the morning until two-thirty in the afternoon. A hot lunch is 
served at eleven-thirty. The classes range from kindergarten 
up to the sixth grade. The enrolment in 191 1 was 61, while at 
present it is about 70. In 1910 the attendance was 40. Then 
one teacher and an assistant were employed and two 'buses were 



276 

used to gather the children. At present the teaching force con- 
sists of a principal, three teachers and an assistant. A cook is 
employed to prepare the lunches, and three older girls are employed 
to help care for the children at the school. Four 'buses are re- 
quired, each traveling an average of twenty miles in making a 
round trip. They are manned by drivers and the four truant 
officers detailed by the city for the morning trip. On the night 
trip the children are accompanied home by the older girls who 
replace the truant officers in helping the patients out of the 'buses. 

The cooperation of the Visiting Nurses Association, the District 
Physicians, Lakeside Hospital Clinic and Rainbow Cottage is 
had in locating deserving cases, and in taking care of their surgical 
and hygienic needs. A small surgery for making dressings has 
been equipped at the school where a graduate nurse attends 
tri- weekly, and oftener if needed. A physician visits the school 
once a week. For operative procedures the children are taken to 
Lakeside Hospital Clinic and for prolonged convalescence to 
Rainbow Cottage. Children who have recovered so as to be able 
to go to school unattended are returned to the regular grades. 
In 191 1, 15 children were returned to the regular grades, having 
lost very little school time in spite of their illness. 

The Public Library furnishes books for home reading. The 
Board of Education has made the comfort, health and happiness 
of the child its first consideration, while education is considered 
secondary. Most of the children are of average intelligence, but 
there are a few of decidedly low mentality who ought to be placed 
elsewhere. Once a week there is a class in manual training for boys 
and one in clay modeling for the girls, but as yet no special in- 
structor is employed for this work. 

During the summer the Circle endeavors to give each child a 
two weeks' summer outing, and through their nurse to keep track 
of the medical needs of the children. 

The burden of expense is borne as follows: The Board of Edu- 
cation furnishes the school-rooms, the teachers, the 'bus drivers 
and truant officers ; the visiting nurse is paid by a certain private 
individual, while the cost of the lunches, the supplies for medical 
and surgical needs, the employment of the woman who does the 



277 

cooking, and the employment of the three girls who help with 
the children, is met by the Circle. The services of the District 
Physician, Lakeside Clinic and Rainbow Cottage are donated. 

An idea of the type of cases which find their way to the school 
can be obtained from the 191 1 report. 

Tuberculosis of the hip 10 

Tuberculosis of the spine 9 

Infantile paralysis 20 

Congenital dislocation of the hip 4 

Rickets ("Soft Bones ") 4 

Tuberculosis of the knee 5 

Patients under treatment for clubfoot. 2 

Unhealed amputation, arthritis, hydrocephalus, muscular 

dystrophy, disability from old fracture, of each 1 

Of these 57 were patients at Lakeside Hospital Clinic, 5 were 
under the care of private physicians, 1 6 had been both at Lakeside 
and Rainbow Cottage, and 30 have been supplied with braces 
by the Lakeside Brace Fund. In the year 191 1, 192 new cases of 
cripples were investigated, many of whom were sent to Lakeside 
or Rainbow Cottage and are now (19 12) in attendance at the 
school. The 191 1 report shows that during 1910 the cost of 
eight months of school was $1,874.13 to the Circle, and that the 
two months in cooperation with the Board of Education cost the 
Circle $769.47. 

Miss Christiannar, the principal, states that it is impossible with 
the present system and facilities to learn of all the children 
who might be aided by the school. Sometimes the children 
live too far to be reached even by the 'bus. This school is in need 
of more room, of a special teacher for manual training and greater 
facilities in fetching the children to and from their homes. The 
work has undoubtedly established its need for existing, and the 
partial recognition and part support accorded it by the Board of 
Education must ultimately result in the complete control both 
of the work and the finance by the public school system. 

There is aside from this school a home for crippled and invalid 
children called the Holy Cross House, a non-sectarian organization 
occupying temporary quarters at 5609 Wliittier Ave., which 



278 

accepts and cares for children who are permanently invalided 
and which at present has twenty inmates. The expenses of this 
institution are entirely met by private benevolence, except that 
the Board of Education has for three years furnished a teacher 
to give such instruction as can be given. The matron of this 
institution states that in the last year they have had to turn away 
60 suitable cases. 

Investigation shows that while these two institutions are doing 
very creditable work, their facilities are entirely inadequate to 
meet the needs of a city of 600,000 inhabitants. These schools 
show how private enterprise very frequently starts meritorious 
work which it cannot adequately finance, which by right the 
city should carry on, and for which the city will have adequate 
funds (as it now has not) , when it learns to appropriate community 
values through taxation for this purpose, instead of relying upon 
the uncertain benevolences which the wealthy may see fit to give. 



XXX. 

THE WELL FED CHILD. 

By A. L. Benedict, A.M., M.D., Buffalo, Consultant in Digestive Diseases, City and 

Columbus Hospitals ; Attendant, Mercy Hospital ; Editor Buffalo Medical Journal ; 

Author of Golden Rules of Dietetics. 

While acknowledging to the fullest extent, the importance of 
eye-strain, adenoids, defective teeth and various other physical 
handicaps of child life, it may be more than a personal interest 
that warrants the writer in emphasizing the homely subject of 
nutrition in the limited sense. 

First of all, however, it may be allowable to reiterate the opinion, 
opposed as it is to modern tendencies, that the prime function of 
the school is education in the narrow sense of "book larnin." 
In so far as the public school system undertakes the medical care 
of children, it undermines the family physician and fosters a 
socialistic spirit of dependence for which this country is not ripe. 
To the extent that the school systematizes the play and mechanic 
ingenuity, scientific spirit and other spontaneous activities of 
children it creates a breach between child and parent, crushes 
individuality and initiative and necessarily diminishes the liberty 
of the child. The tendency to make the school a center of social 
life has led to the premature development of fraternities with 
their attendant evils; it has offended both the less fortunately 
situated and those who claim for themselves and their children, 
a certain amount of exclusiveness ; it leads social life away from 
natural paths starting with the family. The institution of school 
luncheons, provision of textbooks, clothing, free excursions or 
anything else, which should normally be provided by the parent, 
tends to pauperize, on the one hand, to increase taxation on the 
other. 

These reactionary statements require a qualification that miti- 
gates their severity and modifies their implication. The writer 
would not have a single one of these modern extensions of the 
school activity abandoned. If anything, still more advantage 
should be taken of opportunities afforded by the daily massing 
together of the child population, to investigate, control and benefit 



2 8o 

what is not merely an important part of the community but the 
whole social body in its impressionable stage. 

But, whatever is done, should be with a firm appreciation that 
the school cannot take the place of home life, parental guidance 
and instruction, existing social, religious and hygienic institutions, 
nor of the child's spontaneous and free play and work. The 
educational system should, in everything beyond its primary 
function and in every encroachment on time beyond the ordinary 
schedule, question seriously whether some one of the other factors 
in child development is failing to act. If the failure is due to 
accident or carelessness, the attention of the parents should be 
called to the omission. If, either in individual cases or in abnor- 
mal masses of population, the child is not receiving proper at- 
tention, from inability, of the factor involved, then the munici- 
pality or state should step in, tactfully and kindly, but with the 
full realization that it is supplying amusement, a carpenter's 
bench, a warm and reasonably well ventilated room, trips into 
the country, luncheons, instruction in nature, vaccination, dental 
fillings and what not, for exactly the same reason that exists in 
the case of an orphan. 

To limit this principle to the special subject of this paper, the 
actual supplying of food, in the school, rests on exactly the same 
basis as the establishment of a bread line, soup kitchen, milk 
dispensary or any other donation of food. Of course, no refer- 
ence is made to the occasional cooperation of parents or children, 
for the sake of convenience and economy, as when the school is 
at a considerable distance from the homes; but to the school 
luncheon established as a matter of philanthropy and furnished 
free or at a nominal price. Nor, in the present sense, is any 
reference made to the sale of meals or articles of food, in schools, 
as a matter of business The unpleasant fact remains, however, 
that in certain districts, there exists such a state of poverty or 
of ignorance and carelessness, or of indifference to children's 
welfare, that the school luncheon is a necessity. In such cases, 
we must take the bull by the horns, organize the charity on a 
working basis and, by no means an unimportant item, make the 
fact that it is a charity, as little conspicuous as possible. Another 



281 

matter of importance is that the luncheon should not simply 
satisfy the appetite but should provide at least a third of the 
nutriment required daily, properly assorted, wholesome and 
digestible. Coffee and tea should be barred, and, if soup is used, 
it should contain plenty of meat and vegetables, rice, etc. ; it 
should be free from foul smelling vegetables; and it should be 
accompanied by some form of breadstuff. 

The lunch counters, conducted on a commercial basis at certain 
high schools, etc., may be dismissed in a few words. They should, 
of course, be carefully supervised. The prices charged should be 
reasonable, and based, not on those appropriate to cafes but of 
bakeries and markets, bearing in mind that there is, or should be, 
practically no expense for rent. This item is more important 
than might, at first sight, appear. Not only do the customers 
come from families of all means but economy is a very necessary 
lesson for youths. One of the great problems before us is the 
general increase in the price of necessities and the item of greatest 
relative expense and greatest relative increase of cost during 
recent years for the whole community up to the 5 or 10 per cent, 
of highest income, is food. The rising generation must have a 
standard of minimum charges, to guide them in the home-forming 
stage which for many high school students is only two or three 
years distant and may, indeed, already be anticipated by assistance 
to parents. Persons of moderate means are already beginning 
to view with equanimity, charges for dinners equal to the actual 
cost of a week's adequate rations, and profits in the sale of eatables 
five to ten times as great as in the sale of clothing, fuel, light, 
housing, etc. Foolish pride in allowing such a scale o profit 
to the producer or the various middle men and in allowing such 
an increase in the cost to the consumer will tend still further to 
debase the dollar in purchasing power. 

It goes without saying that both food and water should be 
clean, in the scientific sense of being free from either specific or 
saprophytic germs or from their previous action, tending to fer- 
mentation and putrefaction. It is also plain that the food served 
should be nutritious and of adequate nutritive content. As a 
matter of education, standard viands should be listed to show 



282 

average gross weight, content of various nutritive principles and 
calories, with tables showing the totals needed daily. 

In controlling the bill of fare, the necessity of eating plain, 
wholesome food, should be borne in mind. At the same time, 
such control should not be based on mere prejudice. For example, 
there is no objection to hard boiled eggs, smoked meat, ordinary 
cheeses, pies, doughnuts, cookies, ice cream, eclairs, Charlotte 
Russe, etc., provided that they are fresh and properly made. 
Sugar, as such or incorporated in composite foodstuffs, is a most 
valuable source of energy, easily digested and entirely wholesome. 
No one foodstuff or proximate principle should be used to an 
undue amount and the diet should be properly balanced. Com- 
mon sense, or rather actual fact, based on food analyses and 
studies of digestion, should have more weight than the prejudice 
against articles of food because they are agreeable. Conversely, 
the prejudice in favor of various roots, bulbs, leaves, stalks, etc., 
because they are plain, ordinary foods, should not blind us to 
the fact that some are practically devoid of organic nutrient value, 
and that the great majority are very low in the scale, although 
of service as laxatives and antiscorbutics. 

It is important both from the standpoint of the medical in- 
spector and of the teacher seeking the explanation of inattention, 
naughtiness, dulness and failure to keep up with class averages, 
to remember the experience of many an automobile driver, who 
has tested his batteries, taken out his carbureter, looked over 
his pipes for leaks and finally discovered that his gasoline tank 
was empty. We must not overlook astigmatism, adenoids, 
tuberculous tendencies, the effects of C0 2 , etc., neither must we 
overlook the fact that much of the inefficiency of school children 
is due to inadequate nourishment. 

Many adults find by experience that they can do best on a very 
light breakfast although the fact is contradictory to what is 
known regarding the capacity of the body for storage of nutrients. 
But for school children, whose physical exertion at play and in 
walking or running to and from their work, and whose mental 
application and hours of work exceed that of the majority of 
adults, a hearty breakfast is necessary. Within the last few 



283 

months, it has been borne in upon the writer that the average 
fairly prosperous business man has very short hours, very frequent 
holidays, very long vacations and that, beyond the very general 
planning of his business, he does very little actual work. The 
employee works longer hours but, with a few exceptions, not 
nearly so long in proportion to his state of development and 
resistance as the child is not often required to overstrain himself 
physically and, in whatever kind of work he is engaged, he is, 
for the most part, repeating the same process with ever-increasing 
ease of performance whereas the student is daily encountering 
new and unfamiliar problems. 

With the increase of numbers and density of population, and 
the gradual change in its composition, there is, especially in cities, 
an increasing number of families too poor to provide adequate 
food or too ignorant to purchase and prepare it so as to get the 
ultimate return theoretically possible from the amount actually 
expended. And with poverty, we often find a callous indifference 
to children and a tendency to exploit them as wage earners at a 
too early period. We must remember, too, that for all practical 
purposes, we have a debased currency, so that an income sufficient 
at least for the necessities of life a generation ago, may now 
actually threaten the adequacy of the food supply. In a pitiably 
large number of cases the failure of children to keep up with their 
classes is found to be due to the fact that they are hungry. In 
some cases, direct aid must be given to the family — and in such 
form that the children shall get the benefit from it — in other cases 
advice as to choice and preparation of food and insistence upon 
these points is all that is necessary. 

Even among families of considerable means, the capricious 
appetites of children and lack of personal supervision by parents 
often leads to practically the same state of mal-nutrition as among 
the very poor; at least the children go to school with an insuffi- 
cient breakfast. The use of coffee, tea, and even beer is by no 
means infrequent. The former seem to be equally in use among 
poor and well-to-do, in the one case as a cheaper substitute for 
real food, in the latter as a stimulant in the lack of an appetite. 
Beer is more commonly used by children among the very poor 



284 

and recently foreign population. Otherwise, we do not usually 
find any kind of alcoholic use by children until we reach the stage 
of wine with meals and a sideboard. Unless in an emergency, 
no one should indulge in either alcoholics or xanthine beverages 
till full maturity is reached — if indeed then. 

A very practical difficulty is that the school hours are based 
on a time table which, for many families, has been superseded. 
The adults want a late and light breakfast, a light luncheon and 
a hearty dinner at six or seven. Their evening is protracted 
nearly to the beginning of the next day on the average, and, very 
naturally, the women at least do not want to rise till about the 
time that the children are in school. Even if the children go to 
bed early — and often they do not — it is asking a good deal of 
them to get up before the family, allow plenty of time for a 
leisurely breakfast, and for the "stomach to wake up," deny 
themselves coffee, make a judicious selection of food, and get to 
school properly charged with nourishment. At noon, the gram- 
mar school pupil has to hurry through a meal before the family is 
ready to eat, often before the best part of the luncheon is fully 
cooked. On the other hand, the high school student, allowing 
for the longer single session and the greater average distance, 
comes home to an equal lack of companionship and a cold, or 
warmed up assortment of left-overs. And, in both cases, it is 
usually a luncheon and not the needed dinner. At evening 
dinner time, the child should have a fairly simple meal. To get 
it he must, voluntarily or under compulsion, go without the most 
attractive portions or else must, in order to have the full amount 
of sleep needed, perpetrate the physiologic blunder of trying to 
sleep with the nutritive and emunctory organs taxed to their 
utmost with about half of the liquids, purins, proteids and total 
nutrients of the 24 hours. During the first year of the high school, 
the child has to adapt himself to a shifting of the mid-day meal 
to a point nearly two hours later than his habit. He has a long 
period of hard mental work after a light meal, followed by a short 
period of comparative leisure after what his accumulated appetite 
is apt to make a hearty meal, upon which a still heartier one is 
imposed with barely time for emptying the stomach. And then, 



285 

with a full store of material for mental and physical energy, he 
is expected to remain quietly indoors and go to bed with a full 
stomach and almost every viscus hard at work; or he is blamed 
for indulging in the social habits with reference to which the meals 
are arranged and in which he has the example of his elders. On 
the other hand, if the long single session of the high school has 
exceeded the hungry stage, the pupil takes an insufficient lunch- 
eon, and there is every excuse for the development of functional 
disturbances of digestion which so easily pass into organic disease. 

We expect the child to exercise initiative, judgment and self- 
denial in making the best of a meal schedule which the most 
ingenious planning could scarcely make more inappropriate. If 
he does so, well and good; if not, he was formerly considered dull 
or inattentive or bad. At present, we ascribe his condition to 
various physical defects and faults of hygiene or to heredity, 
but usually overlook a simple and obvious reason. This should 
not be considered as in any sense an objection to or failure to 
appreciate the medical and hygienic importance of the conditions 
that we are investigating but a plea not to forget the matter of 
nutrition. 

It is always unsatisfactory to propound a problem without 
offering a solution. But it must be conceded that, in general, 
we cannot expect the child to exercise prudence, judgment and 
self-denial greater than that of the average adult. In some way, 
the school child's regimen must be adapted to his requirements 
or the community will lose in morbidity, mortality and ineffi- 
ciency. And the adaptation of the regimen seems to require 
parental ability and personal attention, even sacrifice of con- 
venience. 



XXXI. 

TEACHING OF FIRST AID IN SCHOOLS. 

By Charles A. Kinch, M.D., New York. 

The idea of instruction in First Aid to the Injured originated 
in the brain of Prof, von Esmarch, of the University of Kiel, when 
he was Surgeon-General of the German Army. He argued that 
the efficiency of the soldier would be increased, his suffering 
alleviated and often his life would be saved, if his wounds could 
be promptly dressed on the field. Accordingly, every man was 
furnished with a packet sewed into the lining of his coat containing 
a clean compress, a bandage and a strap for a tourniquet to stay 
the flow of blood. The results justified the expectations, and 
after the Franco-Prussian war, he expanded his instructions so 
as to be useful to railway and steamboat officials and employees in 
factories and mines. He added chapters on poisons and house- 
hold emergencies. Good Samaritan Societies were established 
all over the Empire. The idea was transplanted to England, 
and engrafted on the St. Johns Ambulance Associations which 
had been formed to inspire manliness in young men and teach 
them to save people from drowning. In 1882, a First Aid society 
was organized in New York City to give this instruction. Re- 
cently the American National Red Cross has created a very 
efficient First Aid department, for instruction in all the large 
cities of the country, New York being left to the society already 
established there. The Pullman Company has given the Red 
Cross a railway car completely equipped with appliances both 
for giving and teaching First Aid. Many of the western railroads 
and lately the Pennsylvania have welcomed this instruction. 
The Bureau of Mines has also made a liberal use of the Pullman 
First Aid cars. Many classes have been formed in settlements 
and neighborhood houses. The New York Board of Education 
regularly includes this subject in its courses of free lectures and 
a very large number of those attending have submitted to exami- 
nation and received diplomas. The question of including First 
Aid in the scheme of public instruction has been broached. The 



287 

Boy Scouts and similar organizations of boys all over the country 
have taken up the matter, all of which leads us to the inquiry: 
At what age is instruction in First Aid best to be given? 

The average boy is content to be in "leading strings" until his 
tenth or eleventh year. At this age he aspires to be a leader, 
or at least to be a member of a gang. Altruistic principles do 
not develop until a couple of years later. Neither is cooperation 
or team work well done before the thirteenth or fourteenth year. 
Then the boy realizes that he has a neighbor and he wants 
to do something for that neighbor. His sufferings appeal to the 
boy's sympathies. Then also he is able to understand the mecha- 
nism of the human body and has acquired a certain amount of 
dexterity in the use of his own hands and members. And he has 
attained a measure of stature and strength that make him effi- 
cient in rendering prompt aid to the injured. 

Of girls, about the same things may be said. They are more 
capable of serious altrustic thought after the thirteenth year than 
in their childhood days. And by that physical and mental 
development better able to comprehend and apply the principles 
of First Aid. 

Nothing in the foregoing is to be construed as discouraging 
special instruction for imminent needs. But just as correct 
speech is taught from the earliest days and the study of grammar 
and rhetoric deferred until riper years, so should instruction in 
First Aid be fragmentary and adapted to present emergencies 
in the case of little children and its systematic study be postponed 
to the third or fourth year of the high school curriculum. In 
social and settlement work the proper pupils for instruction are 
to be found in working girls' clubs and young men's classes 
rather than the junior organizations. 



Index. 



Allport, Frank, M.D., Chicago. The school nurse 249 

Backward, Remediable conditions in the feeble-minded and — . Wal- 
ter Stewart Cornell, M.D., Philadelphia 11 

Bates, Mary Elizabeth, M.D., Denver. The Colorado method for the 

examination and care of public school children 216 

Benedict, A.L., A.M., M.D., Buffalo. The well fed child 279 

Child labor vs. the conservation of school children. Owen R. Lovejoy, 

New York 63 

Child, The teaching of social ethics, and its relation to the conserva- 
tion of the — . Winfield S. Hall, Ph.D., M.D., Chicago 201 

Child, The well fed — . A. L. Benedict, A.M., M.D., Buffalo 279 

Children, The importance of early recognition of surgical affections 

in — . Charles D. Lockwood, M.D., Pasadena, Cal 238 

Classification of the feeble-minded based on mental age. A. C. Rogers, 

M.D., Faribault, Minn 184 

Cleveland, Management, maintenance and efficiency of the school for 

cripples in — . J. E. Tuckerman, A.B., M.D., Cleveland 275 

Colorado method for the examination and care of public school children, 

The. Mary Elizabeth Bates, M.D., Denver 216 

Cornell, Walter Stewart, M.D., Philadelphia. Remediable conditions in 

the feeble-minded and backward 11 

Cripples, Management, maintenance and efficiency of the school for — 

in Cleveland. J. E. Tuckerman, A.B., M.D., Cleveland 275 

Desirability of teaching preventive medicine in the higher institutions 
of learning, The. Henry Bixby Hemenway, A.M., M.D., Evans- 
ton, 111 268 

Edson, Andrew W., New York City. How far shall the public school 

system care for the feeble-minded? 28 

Education for better parenthood. Thomas D. Wood, A.M., M.D., New 

York -. in 

Education for parenthood. Helen C. Putnam, A.B., M.D., Providence 121 

Edwards, J. F., A.M., M.D., Pittsburgh, Pa. Medical inspection of 

schools from the point of view of the health officer 138 

Egbert, Seneca, A.M., M.D., Philadelphia. Teaching hygiene in public 

schools: What should be taught? The physician's view 73 

Ehinger, C. E-, M.D., West Chester, Pa. Indirect methods of teaching 

hygiene 132 

Feeble-minded, Classification of the — based on mental age. A. C. 

Rogers, M.D., Faribault, Minn 184 



290 

Feeble-minded, How far shall the public school system care for the — ? 

Andrew W. Edson, New York City 28 

Feeble-minded, How far shall the public school system care for the — ? 

James H. Van Sickle, Springfield, Mass 36 

Feeble-minded, How far shall the public school system care for the — ? 

E. Bosworth McCready, M.D., Pittsburgh 41 

Feeble-minded, Method of securing state appropriations for proper 
segregation and care of — . Joseph S. Neff, M.D., LL.D., D.P.H., 
Philadelphia 23 

Feeble-minded, Remediable conditions in the — and backward. Wal- 
ter Stewart Cornell, M.D., Philadelphia 11 

First aid, Teaching of — in schools. Charles A. Kinch, M.D., New York 286 

Foreword 3 

Goddard, Henry H., Ph.D., Vineland, N. J. Sterilization and segrega- 
tion 53 

Goodenough, Edward W., M.D., Waterbury, Conn. Medical inspec- 
tion of schools 261 

Grayson, Thomas Wray, A.M., M.D., Pittsburgh. Open air schools.. . . 255 

Hall, Winfield S., Ph.D., M.D., Chicago. The teaching of social ethics, 

and its relation to the conservation of the child 201 

Health supervision, The teacher's relation to — in schools. Ernest 

Bryant Hoag, A.M., M.D., St. Paul, Minn 241 

Hemenway, Henry Bixby, A.M., M.D., Evanston, 111. The desirability 
of teaching preventive medicine in the higher institutions of learn- 
ing 268 

Hoag, Ernest Bryant, A.M., M.D., St. Paul, Minn. The teacher's re- 
lation to health supervision in schools 241 

How far shall the public school system care for the feeble-minded? 

Andrew W. Edson, New York City 28 

How far shall the public school system care for the feeble-minded? 

E. Bosworth McCready, M.D., Pittsburgh 41 

How far shall the public school system care for the feeble-minded? 

James H. Van Sickle, Springfield, Mass 36 

How should hygiene be taught? Louis Nusbaum, Philadelphia 99 

Hughes, Percy, A.M., Ph.D., Lehigh University. Teaching hygiene: 

What should be taught? From the teacher's view point 79 

Hygiene, How should — be taught? Louis Nusbaum, Philadelphia. . . 99 

Hygiene, Indirect methods of teaching — . C. E. Ehinger, M.D., West 

Chester, Pa 132 

Hygiene, Teaching — in public schools : What should be taught ? The 

physician's view. Seneca Egbert, A.M., M.D., Philadelphia 73 

Hygiene, Teaching of — . Methods in vogue. W. S. Steele, A.M., 

LLB., Harrisburg, Pa 92 

Hygiene, Teaching — . What should be taught? From the teacher's 

view point. Percy Hughes, A.M., Ph.D., Lehigh University 79 



291 

Importance of early recognition of surgical affections in children, The. 

Charles D. Lockwood, M.D., Pasadena, Cal 238 

Indirect methods of teaching hygiene. C. E. Ehinger, M.D., West 

Chester, Pa 132 

Kinch, Charles A., M.D., New York. Teaching of first aid in schools. 286 

Lockwood, Charles D., M.D., Pasadena, Cal. The importance of early 

recognition of surgical affections in children 238 

Lovejoy, Owen R., New York. Child labor vs. the conservation of 

school children 63 

McCready, E- Bosworth, M.D., Pittsburgh. How far shall the public 

school system care for the feeble-minded? 41 

Management, maintenance and efficiency of the school for cripples in 

Cleveland. J. E. Tuckerman, A.B., M.D., Cleveland 275 

Medical inspection in schools from the standpoint of the educator. 

Thomas A. Storey, M.D., Ph.D., New York 148 

Medical inspection of schools. Edward W. Goodenough, M.D., Water- 
bury, Conn 261 

Medical inspection of schools from the point of view of the health officer. 

J. F. Edwards, A.M., M.D., Pittsburgh, Pa 138 

Method of securing state appropriations for proper segregation and care 

of feeble-minded. Joseph S. Neff , M.D., LL.D., D.P.H., Philadelphia 23 

Neff, Joseph S., M.D., LL.D., D.P.H., Philadelphia. Method of se- 
curing state appropriations for proper segregation and care of 
feeble-minded 23 

Nusbaum, Louis, Philadelphia. How should hygiene be taught? 99 

Open air schools. Thomas Wray Grayson, A.M., M.D., Pittsburgh.. . . 255 

Parenthood, Education for — . Helen C. Putnam, A.B., M.D., Provi- 
dence 121 

Parenthood, Education for better — . Thomas D. Wood, A.M., M.D., 

New York in 

Prevention of infection of the respiratory tract in the schools, The. 

William Charles White, M.D., Pittsburgh 158 

Preventive medicine, The desirability of teaching — in the higher in- 
stitutions of learning. Henry Bixby Hemenway, A.M., M.D., 
Evanston, 111 268 

Public school system, How far shall the — care for the feeble-minded? 

Andrew W. Edson, New York City 28 

Public school system, How far shall the — care for the feeble-minded? 

James H. Van Sickle, Springfield, Mass 36 

Public school system, How far shall the — care for the feeble-minded? 

E. Bosworth McCready, M.D., Pittsburgh 41 

Public schools, Teaching hygiene in — : What should be taught? 

The physician's view. Seneca Egbert, A.M., M.D., Philadelphia... 73 

Putnam, Helen C, A.B., M.D., Providence. Education for parenthood... 121 



292 

Relative physical advantages of school lunches in elementary and 

secondary schools. Ira S. Wile, M.S., M.D., New York 174 

Remediable conditions in the feeble-minded and backward. Walter 

Stewart Cornell, M.D., Philadelphia 1 r 

Rogers, A. C, M.D., Faribault, Minn. Classification of the feeble- 
minded based on mental age 184 

Royster, L. T., M.D., Norfolk, Va. The subnormal school child 194 

School child, The subnormal — . L. T. Royster, M.D., Norfolk, Va. . . 194 

School children, Child labor vs. the conservation of — . Owen R. 

Lovejoy, New York 63 

School children, The Colorado method for the examination and care of 

public — . Mary Elizabeth Bates, M.D., Denver 216 

School lunches, The relative physical advantages of — in elementary 

and secondary schools. Ira S. Wile, M.S., M.D., New York 174 

School nurse, The. Frank Allport, M.D., Chicago 249 

Schools, Medical inspection in — from the standpoint of the educator. 

Thomas A. Storey, M.D., Ph.D., New York 148 

Schools, Medical inspection of — . Edward W. Goodenough, M.D., 

Waterbury, Conn 261 

Schools, Open air — . Thomas Wray Grayson, A.M., M.D., Pittsburgh. . 255 

Schools, Teaching of first aid in — . Charles A. Kinch, M.D., New York. . 286 

Schools, The prevention of infection of the respiratory tract in the — . 

William Charles White, M.D., Pittsburgh 158 

Schools, The teacher's relation to health supervision in — . Ernest 

Bryant Hoag, A.M., M.D., St. Paul, Minn 241 

Segregation, Method of securing state appropriations for proper — and 
care of feeble-minded. Joseph S. Neff, M.D., LL.D., D.P.H., 
Philadelphia 23 

Segregation, Sterilization and — . Henry H. Goddard, Ph.D., Vine- 
land, N. J 53 

Social ethics, The teaching of — , and its relation to the conservation of 

the child. Winfield S. Hall, Ph.D., M.D., Chicago 201 

State appropriations, Method of securing — for proper segregation and 
care of feeble-minded. Joseph S. Neff, M.D., LL.D., D.P.H., 
Philadelphia 23 

Steele, W. S., A.M., LL.B., Harrisburg, Pa. Teaching of hygiene — 

methods in vogue 92 

Sterilization and segregation. Henry H. Goddard, Ph.D., Vineland, 

N.J 53 

Storey, Thomas A., M.D., Ph.D., New York. Medical inspection in 

schools from the standpoint of the educator 148 

Subnormal school child, The. L. T. Royster, M.D., Norfolk, Va 194 

Surgical affections, The importance of early recognition of — in chil- 
dren. Charles D. Lockwood, M.D., Pasadena, Cal 238 



293 

Teacher's relation to health supervision in schools, The. Ernest Bryant 

Hoag, A.M., M.D., St. Paul, Minn 241 

Teaching hygiene in public schools: What should be taught? The 

physician's view. Seneca Egbert, A.M., M.D., Philadelphia 73 

Teaching hygiene : What should be taught? From the teacher's view 

point. Percy Hughes, A.M., Ph.D., Lehigh University 79 

Teaching of first aid in schools. Charles A. Kinch, M.D., New York. . . . 286 

Teaching of hygiene — methods in vogue. W. S. Steele, A.M., LL.B., 

Harrisburg, Pa 92 

Teaching of social ethics, and its relation to the conservation of the 

child, The. Winfield S. Hall, Ph.D., M.D., Chicago 201 

Tuckerman, J. E., A.B., M.D., Cleveland. Management, maintenance 

and efficiency of the school for cripples in Cleveland 275 

Van Sickle, James H., Springfield, Mass. How far shall the public 

school system care for the feeble-minded? 36 

Well fed child, The. A. L. Benedict, A.M., M.D., Buffalo -279 

White, William Charles, M.D., Pittsburgh. The prevention of infection 

of the respiratory tract in the schools 158 

Wile, Ira S., M.S., M.D., New York. The relative physical advan- 
tages of school lunches in elementary and secondary schools 174 

Wood, Thomas D., A.M., M.D., New York. Education for better 

parenthood m 

Schools, Medical inspection of — from the point of view of the educa- 
tor. J. F. Edwards, A.M., M.D., Pittsburgh, Pa 138 



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